Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 New Lexington during CMS and state inspections, most recent first.
Expired medications were found in a medication room and a medication cart, including opened and unopened bottles of sodium chloride, zinc, aspirin, vitamins, a HypoPen glucagon injection, IV meropenem, and acidophilus. An LPN verified the expired items, while the DON stated floor nurses were expected to routinely check medication rooms for expired medications. A consulting pharmacist report also noted expired medications in medication and treatment carts and items not stored per manufacturer guidelines.
Expired coffee creamer was found in the kitchen dry storage area, including four large containers that were past their expiration dates. The Dietary Manager confirmed the items were present and stated they were not used by the kitchen, but were used by activity staff.
Failure to document COVID-19 vaccine education and offering for four residents. Record review showed that a resident with COPD, DM, HF, and CAD, a resident with COPD, DM, and dementia, a resident with dementia, TBI, and DM, and a resident with Parkinson's disease and TBI had no evidence of education or offer of the updated annual COVID-19 vaccine. RN confirmed the missing documentation, and the facility reported the prior IP no longer worked there and immunization consents were not otherwise available.
Missing Signed Consent for Psychotropic Medications: A resident with schizo-affective disorder, dementia, bipolar disorder, major depressive disorder, and anxiety received psychotropic meds including Duloxetine, Remeron, and Clonazepam. The record showed signed consent for some antipsychotics, but the consent form for Duloxetine and Remeron was not signed by the resident, and the DON and RN confirmed there was no documented signed consent showing the risks and benefits had been explained for those meds.
Room Not Kept in Good Repair: A resident with intact cognition and diagnoses including hemiplegia/hemiparesis after CVA and anxiety disorder reported multiple room maintenance issues, including wall patches, scuffs, a missing bed wheel, a cracked and loose bathroom door cover with sharp edges, peeled paint, and holes in the bathroom wall. A CNA confirmed the condition of the room and that the toilet paper and paper towel holders had been moved without repairs, despite the resident stating the room had been in that condition for a while.
A resident with schizophrenia and dementia was placed in a locked memory care unit after the IDT noted increased falls and attempts to drink hand sanitizer, but the elopement risk assessment showed no elopement risk and there was no additional assessment or documentation supporting medical necessity for the secure unit. The DON verified no assessment or other documented medical necessity existed before the resident was admitted to the locked unit.
Failure to monitor psychotropic medication side effects for a resident with depression and anxiety. The resident was receiving an antidepressant and an antianxiety medication, but the physician order list did not include monitoring orders and the MARs showed no documentation of side effect assessments. An LPN and the DON confirmed that side effect monitoring was expected for residents on psychotropic medications.
A resident with acute kidney failure, kidney transplant status, urinary retention, and anxiety disorder was sent to the ER for a change in condition and admitted to the hospital without returning. The record contained no transfer notice or bed hold notice for the resident or family, and the Administrator and former SW both confirmed the notices were not issued because they believed the resident’s advantage plan and discharge status made them unnecessary, despite acknowledging transfer notices apply to hospital transfers and residents may have bed-hold options regardless of payor source.
Missing Care Plan for Suicidal Ideations: A resident admitted with dementia, anxiety disorder, paranoid personality disorder, and suicidal ideations had severely impaired cognition and delusions on MDS review, but the care plan did not address the history of suicidal ideations. The DON confirmed the absence of a care plan for this need, despite facility policy requiring a comprehensive person-centered care plan with measurable objectives and timeframes.
Failure to Follow Suicidal Ideation Protocol: A resident with dementia, anxiety disorder, paranoid personality disorder, and a history of suicidal ideations made suicidal statements after becoming upset about missing clothing. The RN stayed with the resident and provided comfort, but there was no documented provider notification, no new orders, no room search, and no care plan related to suicidal ideation. Interviews confirmed no documented physician notification or social services follow-up, despite the facility’s protocol requiring immediate reporting and continued line-of-sight supervision.
Failure to Document BP With Antihypertensive Administration: A resident receiving Metoprolol Succinate ER for HTN had an order requiring the nurse to notify the MD if SBP was below 100 mmHg, but the MAR did not show BP checks at the time of administration. BP monitoring was sporadic, with no readings documented for one month and only two readings the next month, and the DON confirmed the MARs did not show evidence that BP was monitored when the medication was given.
A resident with Parkinson's disease and edema did not receive ordered q3mo lab draws, including CBC, BMP, vitamin levels, lipid panel, liver panel, and prealbumin. The record showed the last labs were completed months earlier, with no results for two scheduled draws, and the ADM confirmed the labs were not obtained as ordered.
A resident with dementia, depression, dysphagia, and anxiety did not receive timely dental services after repeated dental consults referred the resident to an oral surgeon for extraction of symptomatic teeth. Staff documented faxing referrals and sending an email, but no oral surgery appointment was made, and there was a documented gap in efforts to secure the consult. An RN later noted tooth pain, a missing upper tooth, and cold sensitivity, while the TA confirmed no appointment had been arranged and that insurance was not contacted to locate a provider.
A resident with rectal cancer and a colostomy had orders for multiple JP drains to be emptied and documented every shift, but the TAR and progress notes did not show recorded drainage amounts for several shifts. The DON confirmed the missing output documentation, and there was no progress note evidence that the drain care or ordered wound treatments were completed.
Surveyors found that the facility failed to implement and document comprehensive, individualized pressure ulcer prevention and treatment for two residents. One resident, identified as high risk for skin breakdown and later experiencing falls, cognitive decline, infections, weight loss, and decreased mobility, did not receive an integrated, escalated skin care plan or consistent turning/repositioning, and subsequently developed large, discolored heel wounds and a Stage II coccygeal pressure injury. Another resident with an existing sacrococcygeal pressure ulcer and total dependence for turning and repositioning had detailed wound care orders, but treatment records showed multiple missed or undocumented dressing changes on both day and night shifts, with the DON confirming there was no evidence the ordered wound care was completed on those dates.
Two residents with serious infections and complex medical conditions did not consistently receive ordered treatments and monitoring. One resident with MSSA infection and endocarditis had a chest wound for which a wound vac was indicated at discharge, but there was no facility order or documentation of wound vac use, and ordered daily Dakins wound care was missed on multiple days without explanation. The same resident’s IV cefazolin was not administered for several scheduled doses when the medication did not arrive from the pharmacy, and there was no documentation of physician or resident/representative notification or alternate orders. Another resident with a thoracic epidural abscess, CKD, CHF, and an unstageable pressure ulcer had orders for daily weights, IV meropenem, and every-shift I&O monitoring, yet numerous daily weights, several meropenem doses, and multiple I&O entries across various shifts were not documented, as confirmed by the DON.
A resident with multiple complex conditions, including UTI, spinal cord issues, CKD, an unstageable pressure ulcer, and diabetes, had a physician order for weekly morning CBC, e-diff, platelets, BMP without glucose, and hepatic function panel during Meropenem therapy, with results to be sent to the physician. Record review showed that the ordered labs were not completed on two scheduled weeks, and the DON confirmed there was no evidence the labs were obtained as ordered.
Multiple bathrooms were found with rusted holes in sinks, including a private room and a shared bathroom, affecting four residents. Facility leadership confirmed the presence of these hazards, which were identified during a facility audit and through direct observation, in violation of the facility's policy for a safe and homelike environment.
A resident with an implanted vascular access port received IV antibiotics and had the port accessed without a valid physician's order or supporting documentation for the diagnosis. Interviews with the attending physician, CNP, and other providers confirmed that no order was given for the antibiotic or port access, and the RN who entered the order could not verify its source. Facility guidelines require a physician's order for port access, but this was not followed.
A resident with multiple health issues, including multiple sclerosis and cognitive impairment, did not receive necessary incontinence care and repositioning while in her wheelchair for over six hours. Despite being dependent on staff for personal care, she was left unattended and not repositioned, leading to concerns from her family. Staff interviews confirmed the lack of care, and the facility's DON acknowledged previous family concerns about the issue.
A resident admitted with respiratory failure and muscle weakness was not involved in discharge planning, despite being cognitively intact and expressing a desire to return home. The facility's policy required discharge planning upon admission, but the social worker was unaware of the resident's goal until later, leading to an unplanned discharge. This deficiency affected the resident's right to self-determination and choice.
A resident with a pressure ulcer did not receive proper care due to the facility's failure to update the care plan with necessary interventions. The resident's low air loss mattress was set incorrectly for their weight, and staff were unsure of its function. The facility's policy on pressure ulcer prevention was not followed, resulting in a deficiency.
A facility failed to set parameters for administering as-needed diuretic medication for a resident with severe cognitive impairment and heart failure. The resident's medical record included an order for furosemide to be given as needed for weight gain, but lacked specific instructions on the required weight gain. Additionally, the care plan did not address the use of diuretics, daily weight monitoring, or the heart failure diagnosis. Interviews with an LPN and the DON confirmed these omissions.
A facility failed to maintain infection control procedures during a dressing change for a resident with pressure ulcers. An LPN did not wash her hands between glove changes while treating a resident with multiple sclerosis and other conditions, contrary to the facility's wound care policy.
Expired medications found in medication room and cart
Penalty
Summary
The facility failed to dispose of expired medications and biologicals in accordance with its medication storage requirements. During review of one medication room and two medication carts, surveyors found multiple expired items, including opened and unopened bottles of sodium chloride, zinc, aspirin, vitamin B12, vitamin B6, vitamin B1, a HypoPen glucagon injection, and three IV bags of meropenem in the medication room, as well as expired acidophilus and aspirin in a medication cart. The LPNs present verified the expired medications during observation. The most recent consulting pharmacist report dated 03/02/26 documented audits of medication rooms, medication and treatment carts, and cold storage, and noted expired medications in medication carts and treatment carts, along with items not stored per manufacturer guidelines. The DON stated that floor nurses were expected to routinely check medication rooms for expired medications. The facility policy titled Medication Storage, dated 01/02/2024, stated that the pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels.
Expired Coffee Creamer Kept in Dry Storage
Penalty
Summary
The facility failed to ensure expired food items were not kept in the kitchen. During an observation of the dry storage area, four large containers of coffee creamer were found expired, with two expired on 12/24/19 and two expired in 03/2020. The Dietary Manager confirmed the expired coffee creamers were in the dry storage area and stated they were not used by the kitchen, but were used by activity staff.
Failure to Document COVID-19 Vaccine Education and Offering
Penalty
Summary
The facility failed to ensure residents were educated on the updated annual COVID-19 vaccine and given the opportunity to receive it if they desired. Record review showed that Resident #2, Resident #5, Resident #7, and Resident #68 all had informed consent records that did not contain evidence of education about the COVID-19 vaccine for the 2025-2026 respiratory illness season or documentation that the vaccine was offered. The last documented COVID-19 vaccine for Residents #2 and #5 was 10/09/24, and the records for Residents #7 and #68 also lacked evidence of education or offering of the updated vaccine. The four affected residents had significant medical histories, including COPD, adult onset diabetes mellitus, dementia, heart failure, chronic ischemic heart disease, Parkinson's disease, morbid obesity, traumatic brain injury, and personal histories of COVID-19. During interview, RN #110 confirmed there was no documented evidence that any of the four residents had been educated on the COVID-19 vaccine or given the opportunity to receive it during the 2025-2026 respiratory illness season. The facility also stated that the prior Infection Preventionist no longer worked there and that they did not have access to any immunization consents other than those already provided.
Missing Signed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure a resident receiving psychotropic medications signed consent after the risks and benefits of those medications were explained. Resident #5 was admitted with diagnoses including schizo-affective disorder, dementia, bipolar disorder, major depressive disorder, and anxiety. The quarterly MDS indicated he was cognitively intact, able to make himself understood, and able to understand others. During the review period, he received antipsychotic medications, anti-anxiety medications, and antidepressants, including Duloxetine 60 mg twice daily for major depressive disorder and Remeron 7.5 mg at bedtime for angry outbursts. The record showed informed consent documentation for Invega, Olanzapine, and Aripiprazole was signed by the resident, but the informed consent form for Duloxetine and Remeron was not signed by Resident #5. A psychoactive medication consent and management agreement for Clonazepam showed the resident’s initials and an effective date matching the latest order, and the progress note stated the nurse practitioner decreased the Clonazepam dose and that the resident and family were made aware of the new order. However, the DON and RN confirmed there was no signed consent in the record for Duloxetine and Remeron, and the DON stated the facility did not have evidence that the resident had been educated on the risks and benefits of Clonazepam before the consent form was obtained.
Room Not Kept in Good Repair
Penalty
Summary
The facility failed to ensure that a resident’s room was kept in good repair, affecting one resident reviewed for environmental concerns. The resident was admitted with diagnoses including hemiplegia and hemiparesis following a cerebrovascular accident and an anxiety disorder, and the MDS assessment indicated the resident’s cognition was intact. During interview and observation, the resident stated the room had large white patches on the wall next to the window, black scuffs on the bottom of the walls in the entryway, a missing wheel on the left upper side of the bed, and a lower bathroom door cover that was cracked, loose, and had sharp edges. The resident also pointed out that the paper towel holder had been moved, paint had peeled away and was not repaired, and there were two holes in the bottom of the bathroom wall under the toilet paper holder and behind the toilet. The resident further stated he did not like the condition of the room and wished it would be fixed, but it had been that way for a while, and he said he would not let his home be in disrepair. A CNA later confirmed the white patches on the wall near the window, the black scuffs in the entryway, the cracked and broken bathroom door cover, the two holes in the bathroom walls, and that the toilet paper and paper towel holders had been moved without repairing the areas. The facility policy on Resident Rights stated residents have the right to a safe, clean, comfortable, and homelike environment.
Lack of documented medical necessity for locked memory care placement
Penalty
Summary
The facility failed to ensure Resident #24 was comprehensively assessed and had documented medical necessity to reside in the locked memory care unit. Resident #24 was admitted with diagnoses including schizophrenia and dementia, and an elopement risk assessment showed the resident was not at risk for elopement. A late entry IDT note stated the team reviewed the resident’s situation because of increased falls and attempts to drink hand sanitizer throughout the facility, and that the resident and family agreed to move to the locked memory care unit to increase activity time and monitor closely. An order later stated the resident resided on the secure unit to meet physical, mental, spiritual, emotional well-being and safety needs, but there was no additional documentation supporting the need for placement in the memory care unit. The Administrator verified there was no assessment and no other medical necessity documented before the resident was admitted to the locked unit.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to monitor potential side effects of psychotropic medications for one resident who was reviewed for unnecessary medications. The resident had diagnoses of depression and anxiety disorder and was receiving Duloxetine HCl 20 mg twice daily for depression and Lorazepam 1 mg twice daily for restlessness and anxiety, with an additional Lorazepam dose available every hour as needed for restlessness and anxiety. The physician order list for March 2026 did not include any orders to monitor for side effects of the antidepressant or antianxiety medications. The resident’s care plan, initiated on 10/03/25, identified that the resident received psychotropic medication and was at risk for adverse side effects. However, review of the Medication Administration Records for December 2025, January 2026, and February 2026 showed no documentation of assessment for adverse side effects of psychotropic medications. An LPN confirmed that nursing staff were expected to monitor behaviors and medication side effects when a resident was ordered a psychotropic medication, and stated that an order to monitor for side effects should be present on the physician’s order list and documented in the MAR. The DON also confirmed that the facility should monitor side effects for all residents with current psychotropic medication orders and stated that this monitoring is reflected as an order on the clinical physician’s order list.
Missing transfer and bed hold notices after hospital transfer
Penalty
Summary
The facility failed to ensure that a resident transferred to the hospital received a transfer notice and a bed hold notice at or around the time of transfer. Resident #74 was admitted with diagnoses including acute kidney failure, kidney transplant status, retention of urine, and anxiety disorder. A progress note documented that the resident had a change in condition and was sent to the emergency room for evaluation, after which he was admitted to the hospital and did not return to the facility. The resident’s closed medical record contained no evidence that a transfer notice or bed hold notice was provided to the resident or his family at or around the time of transfer. During interviews, the Administrator confirmed the facility did not have a transfer notice or bed hold notice for the resident’s hospital transfer and stated she believed the notices were not required because the resident was covered under an advantage plan and would be treated as a discharge. The former social worker, now the business office manager, also confirmed he did not issue either notice and stated he believed transfer notices were not required for residents discharged from the facility and that bed hold notices were not needed for payors other than Medicaid. He acknowledged that transfer notices were to be given to residents transferred from the facility to the hospital and that all residents should have the option to hold a bed regardless of payor status.
Missing Care Plan for Suicidal Ideations
Penalty
Summary
Comprehensive resident-centered care plans were not in place for Resident #12, who was admitted with diagnoses including dementia, anxiety disorder, paranoid personality disorder, and suicidal ideations. The MDS assessment showed the resident had severely impaired cognition, delusions, and other behaviors occurring one to three days during the review period. Review of the care plan dated 02/03/26 showed no care plan addressing the resident’s history of suicidal ideations. During interview on 03/11/26 at 12:43 P.M., the DON confirmed that Resident #12 did not have a care plan in place to address the history of suicidal ideations. The facility policy stated that a comprehensive person-centered care plan should include measurable objectives and timeframes to meet the resident’s medical, nursing, and psychosocial needs and be developed within seven days after completion of the comprehensive MDS.
Failure to Follow Suicidal Ideation Protocol
Penalty
Summary
The facility failed to follow its protocol after a resident with dementia, anxiety disorder, paranoid personality disorder, and a history of suicidal ideations made suicidal statements. Nursing documentation showed that when the resident became upset about not finding her jackets, she screamed that she was going to kill herself. The RN stayed with the resident, attempted to calm her, provided comfort measures, and noted the resident was resting in bed and would continue to be monitored. There was no evidence that the provider was notified at the time of the incident, no new orders were obtained, and no room search was documented. The resident’s behavioral health note later reflected that staff reported the resident’s behaviors were at baseline and that there were no reports of increased anxiety, insomnia, or appetite problems. An interdisciplinary note later documented discussion of the prior suicidal statements and stated the resident had no plan or means and was upset about clothing items. The care plan dated after the incident did not include a care plan related to the resident’s history of suicidal ideations. Interviews with nursing, social services, and the DON confirmed there was no documented care plan for suicidal ideation, no documented physician notification, and no social services follow-up or support related to the incident. The facility’s suicidal thoughts and ideation procedure stated suicidal thoughts or ideations should be immediately reported to the DON and/or social services, and the resident should remain in staff line of sight during assessment and coordination of services.
Failure to Document Blood Pressure With Antihypertensive Administration
Penalty
Summary
The facility failed to ensure a resident receiving Metoprolol Succinate ER for hypertension had blood pressure obtained and recorded at the time the medication was administered, despite the physician’s order including a parameter to notify the physician if systolic blood pressure was less than 100 mmHg. The resident was admitted with a diagnosis of hypertension and had an order for Metoprolol Succinate ER 25 mg by mouth at bedtime with the SBP notification parameter in place since 08/20/25. Review of the MAR for February and March 2026 showed the medication was administered as ordered, but the MAR did not provide a place to document blood pressure at administration and contained no documented blood pressure readings for those medication passes. The EMR vitals summary showed blood pressures were only sporadically obtained, with none recorded in February and only two in March; one March reading was 90/48, but it was unclear what the resident’s blood pressure was when the medication was given at bedtime on 03/05/26 because no blood pressure had been obtained and recorded at that time. The DON confirmed the order included the SBP parameter and acknowledged the MARs did not show evidence that blood pressure was monitored at the time Metoprolol Succinate was administered.
Missed Ordered Lab Monitoring
Penalty
Summary
The facility failed to complete laboratory work as ordered by the physician for Resident #68, who was admitted with diagnoses including Parkinson's disease and edema and had intact cognition on the MDS assessment. The physician orders dated 07/30/24 required blood draws every three months for CBC, basic metabolic panel, vitamin D, B12, lipid panel, liver panel, and prealbumin in August, November, February, and May. Review of the laboratory results showed the resident last had lab work completed on 08/28/25, and there were no lab results for November 2025 or February 2026 as ordered. The care plan identified the resident as at risk for fluid imbalance due to diuretic use related to edema, and the facility policy required diagnostic tests to be maintained in accordance with physician orders.
Delayed Dental Referral and Oral Surgery Scheduling
Penalty
Summary
The facility failed to ensure timely dental services for one resident who had an admission date of 11/30/23 and diagnoses including dementia with behavioral disturbance, depression, dysphagia, and anxiety disorder. A dental consult dated 09/11/25 showed the resident had been referred to an oral surgeon to extract all symptomatic teeth, and another dental consult dated 01/13/26 again documented the same referral. The record showed multiple attempts by Transportation Aide #176 to arrange dental care, including faxing referrals to Dental Clinic #1, Oral Surgery and Dental Implants #2, and emailing Family Dental #3, but there was no documentation that an oral surgeon appointment was actually made. The record also showed a gap in documented efforts to obtain the oral surgery consult from after the 01/13/26 dental consult until 03/12/26. The resident’s MDS assessment noted severe cognitive impairment, no obvious or likely cavity or broken natural teeth, no facial pain, and no difficulty chewing. On 03/08/26, an RN documented that the resident was having tooth pain and had a right upper tooth missing with cold sensitivity. During interview on 03/12/26, TA #176 verified that no appointment had been made for the oral surgeon consult and stated she had attempted to call others but did not document those efforts and did not contact insurance to find a provider.
Incomplete Documentation of JP Drain Outputs
Penalty
Summary
The facility failed to ensure accurate medical record documentation for Resident #60’s JP drains. The resident was admitted with diagnoses including malignant neoplasm of the rectum and status post colostomy placement, and her initial skin evaluation documented one JP drain in the lower abdominal area and two additional JP drains in the right lower extremity. Physician orders required the abdominal JP drain, JP drain #2, and JP drain #3 to be drained and the output recorded every shift. Review of the TARs showed multiple missed documentation entries for drainage amounts from the JP drains, including no recorded output for the abdominal JP drain and JP drain #3 on two occasions in February 2026, no recorded output for JP drain #2 on one night shift in February 2026, and no recorded output for the abdominal JP drain and JP drain #3 on one night shift in March 2026. The progress notes did not contain evidence that the drainage amounts were emptied and recorded or that the ordered treatments to the surgical wounds were completed, and no refusals were documented. The DON confirmed that the outputs were not recorded for the identified shifts and that the progress notes did not contain documentation of the drainage amounts.
Failure to Prevent and Properly Treat Pressure Ulcers in Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pressure ulcer prevention and care, resulting in the development and worsening of pressure injuries in two residents. One resident was admitted with psychosis, traumatic brain injury, and schizophreniform disorder and was identified early as high risk for skin breakdown due to age and neurological conditions. Her care plan initially noted dry calloused areas on the feet and included general interventions such as incontinence checks, preventative skin care, and weekly skin inspections with physician notification of abnormal findings. A subsequent skin risk evaluation and nursing note identified her as high risk for pressure ulcer development and called for an escalated level of care to preserve skin integrity, but there was no evidence that an integrated, individualized plan of care with specific preventive interventions was implemented following this assessment. Over the following weeks, this resident experienced multiple signs of decline that increased her risk for pressure ulcers, including a fall associated with poor balance, fluctuating and then significant weight loss, increased confusion, muscle weakness, debility, urinary tract infection, urinary retention, presumptive shingles, and edema. Despite these changes, the facility did not recognize or respond to the decline with an integrated or escalated plan of care focused on skin preservation. Documentation showed gaps in turning and repositioning, with no recorded repositioning on one full day and no day-shift repositioning on another day. Skin evaluation assessments shortly before the discovery of heel wounds documented no new skin issues, and when new heel areas were finally documented, they were described as large, discolored, non-blanchable areas with deep purple centers and surrounding discoloration, but were not staged at that time. The resident was later documented to have two unstageable pressure ulcers on both heels and a Stage II pressure ulcer on the sacrum. Orders to offload the heels in bed, apply specific dressings, and encourage time up in a chair for wound healing were initiated only after the heel wounds were identified. The DON confirmed that prior to the skin breakdown, the resident did not have a comprehensive, integrated plan of care with preventive interventions for skin breakdown, despite her overall decline in mobility, cognition, infections, and weight loss. A regional nurse later characterized the heel areas as deep tissue injuries rather than unstageable ulcers, and the attending physician attributed the skin breakdown largely to nutrition issues, sepsis, and immobility and suggested the sacral wound might be a Kennedy ulcer, but there was no supporting documentation in the record for this. A second resident, admitted with multiple serious conditions including an existing unstageable pressure ulcer, required extensive assistance with ADLs, was dependent for turning and repositioning, and had an indwelling catheter with frequent bowel incontinence. Physician orders specified detailed wound care for a sacrococcygeal pressure ulcer, including cleansing, application of Triad hydrophilic dressing, and later a change to alginate dressing with zinc barrier and ABD cover. Review of the treatment records for the month showed multiple dates on which the ordered wound care was not documented as completed on both day and night shifts. The DON verified there was no evidence that the sacrococcygeal wound treatments were completed as ordered on those dates. These omissions in following prescribed wound care orders for an existing pressure ulcer constituted a failure to provide the ordered pressure ulcer treatment for this resident.
Failure to Follow Physician Orders for Wound Care, IV Antibiotics, Weights, and I&O Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered treatments and medications for two residents with serious infections and other comorbidities. One resident with MSSA infection, endocarditis, and altered mental status was admitted with a thoracic/chest wound that, per email and attached orders, required a wound vac at a specified pressure setting with continuous suction and dressing changes three times weekly and as needed. The hospital discharge summary indicated the resident was to continue cefazolin with weekly labs and that the wound vac was in place at discharge, with no order to discontinue it. However, the facility’s medical record contained no evidence that a wound vac order was entered, that the wound vac was to be discontinued, or that the resident refused it. Instead, a subsequent order directed daily Dakins-based wound care to the left chest incision, and the treatment record showed that this wound care was not provided on multiple specified dates, with no nursing notes explaining the missed treatments. The same resident had an order for IV cefazolin 2 g every eight hours for infection, with a defined end date. The MAR showed the 6:00 a.m. dose on one date was given, but subsequent scheduled doses over the next day and a half were not administered because the medication was not available from the pharmacy. A nursing note documented that the pharmacy reported the medications had left the pharmacy and were still en route, yet there was no documentation that the resident or representative was notified, nor that the physician was notified or provided new orders to hold the medication or use backup stock. In interview, the DON confirmed the IV medications were not given as ordered due to non-arrival from the pharmacy, that providers were not notified, and that no new orders were obtained. A second resident with diagnoses including UTI, cord compression, extradural and subdural abscess, CKD, unstageable pressure ulcer, and diabetes had multiple physician orders that were not consistently followed or documented. An order for daily weights with parameters to notify the physician for specified weight gains lacked documented weights on numerous listed days in December. An order for meropenem 1 g IV every eight hours for a thoracic epidural abscess until a specified end date showed no documented administration on three specific dates. Additionally, an order to monitor intake and output every shift for fluid restriction and CHF had multiple shifts with no intake and output documentation on both day and night shifts. In interviews, the DON verified the missing daily weights, missed meropenem doses, and absent intake and output documentation on the identified dates and shifts.
Failure to Obtain Ordered Weekly Laboratory Tests During Antibiotic Therapy
Penalty
Summary
The deficiency involves the facility’s failure to obtain ordered laboratory tests and communicate results to the ordering practitioner for one resident. The resident was admitted with diagnoses including urinary tract infection, cord compression, extradural and subdural abscess, chronic kidney disease, an unstageable pressure ulcer, and diabetes. An admission MDS showed the resident had intact cognition but required extensive assistance with most activities of daily living, had an indwelling catheter, and was frequently incontinent of bowel. A physician’s order dated 12/04/25 directed that a CBC, electronic differential, platelets, BMP without glucose, and hepatic function panel be obtained weekly on Thursday mornings during Meropenem therapy, with results to be sent to the physician. Review of the medical record showed no evidence that the ordered labs were completed on 12/11/25 and 12/25/25, and in an interview the DON confirmed there was no evidence the labs were done as ordered. This was cited as an incidental finding of non-compliance under the referenced complaint number.
Failure to Maintain Safe and Homelike Bathroom Environment
Penalty
Summary
The facility failed to maintain a safe and homelike environment for four residents, as evidenced by the presence of rusted holes in bathroom sinks. During an observation, a private room's bathroom was found to have a quarter-sized rusted hole through the sink. Additional inspection of a shared bathroom for two rooms revealed a baseball-sized rusted hole in the sink. These conditions were confirmed through interviews with the Director of Nursing and the Maintenance Director, who both acknowledged the existence of the rusted holes in the sinks of the affected rooms. A facility-wide audit conducted earlier in the month had identified two sinks with rusted holes, including those in the rooms currently or previously occupied by the affected residents. The facility's policy requires maintaining a safe, clean, and comfortable environment, specifically including resident bathrooms. Despite this policy, the physical environment in these areas was not maintained, resulting in the cited deficiency.
Failure to Obtain Proper Orders for Antibiotic Administration and Vascular Access Port Use
Penalty
Summary
The facility failed to ensure that an antibiotic was ordered correctly and that an implanted vascular access port (port-a-cath) was accessed with a physician's order for one resident. The resident had multiple diagnoses, including partial intestinal obstruction, malignant neoplasm of the colon, malnutrition, osteoarthritis, iron deficiency anemia, hypertension, and a history of venous thrombosis and embolism. The resident was assessed as cognitively intact and required some assistance with activities of daily living. Upon review, the resident's medical record showed the presence of an implanted vascular access port, but there was no care plan focus, goal, or intervention related to the port, and it had not been accessed at admission. A physician's order for intravenous Cefepime HCL was entered by an RN, citing a telephone order from a physician for bacteremia, but there was no supporting provider documentation or laboratory evidence for this diagnosis. The resident's port was accessed by another RN, and the antibiotic was administered. However, subsequent interviews with the physician, nurse practitioner, and other providers revealed that none of them had given an order for the antibiotic or for accessing the port. The RN who entered the order could not recall who provided the telephone order and admitted to entering it under the resident's physician because he was the attending provider. Further interviews with facility leadership and external providers confirmed that there was no documentation or valid order for either the antibiotic or the port access. The facility's own guidelines require a physician's order before accessing a vascular access port, and the checklist for port care specifies that the first step is to review the physician's orders. The deficiency was identified as non-compliance with proper treatment and care according to orders, resident preferences, and goals.
Failure to Provide Adequate Incontinence Care and Repositioning
Penalty
Summary
The facility failed to provide necessary assistance to a resident, identified as Resident #39, who was dependent on staff for personal care, including routine incontinence care and repositioning while in her wheelchair. Resident #39 had multiple health issues, including multiple sclerosis, cognitive impairment, and was at high risk for pressure ulcers. She was completely dependent on staff for mobility and toileting hygiene, as she was always incontinent of bowel and bladder and unable to communicate her needs effectively. On the day of the observation, Resident #39 was noted to be in her tilt space wheelchair from before 7:00 A.M. until 1:05 P.M. without receiving any incontinence care or repositioning. During this time, she was observed leaning to the right side in her wheelchair and was not actively engaged in activities. Despite being moved to different locations within the facility, no staff members were observed to check on her or assist with repositioning or changing her until she was finally taken back to her room and changed at 1:05 P.M. Interviews with facility staff, including a CNA and an LPN, confirmed that Resident #39 was completely dependent on staff for care and required regular checks and changes every two hours. However, it was acknowledged that the resident had not been changed or repositioned for over six hours. The facility's Director of Nursing confirmed that there had been previous concerns from the resident's family about the lack of regular incontinence care, and it was the facility's expectation for staff to complete rounds every two hours to assist residents with their care needs.
Failure to Initiate Discharge Planning Upon Admission
Penalty
Summary
The facility failed to initiate the discharge planning process upon admission for a resident, which affected the resident's right to self-determination and choice. The resident was admitted with diagnoses including chronic and acute respiratory failure, muscle weakness, and difficulty in walking. An interdisciplinary care conference summary indicated that the resident would receive long-term care and apply for Medicaid, but the resident and family did not sign in for this conference. The admission minimum data set (MDS) showed the resident was cognitively intact and had a discharge goal to remain in the facility. However, the resident expressed a desire to go home, which was not communicated to the social worker until later. Interviews revealed that the resident and his wife had not been involved in the discharge planning process, and there was no documentation of a care plan meeting upon re-admission. The social worker was unaware of the resident's goal to return home and was working on an unplanned discharge after being informed of the resident's wishes. The facility's discharge planning policy required initiation of discharge planning upon admission and regular reviews, which were not followed in this case. The lack of communication and documentation led to a deficiency in honoring the resident's right to self-determination and choice.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to maintain a comprehensive plan of care and properly implement pressure-relieving interventions for a resident with a pressure ulcer. The resident, who was admitted with a coccyx suspected deep tissue injury, had multiple diagnoses including type 2 diabetes and peripheral vascular disease. Upon admission, the resident's pressure ulcer was not properly addressed in the care plan, and there was no intervention for a low air loss mattress, despite a physician's order for such a mattress. The resident's Braden Scale score indicated a risk for pressure ulcer development, yet the care plan did not reflect necessary interventions. Observations revealed that the low air loss mattress was set incorrectly for the resident's weight, which was not updated in the care plan. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the mattress settings were incorrect and not specified in the care plan. The facility's policy on pressure ulcer prevention was not followed, as the care plan was not updated with the identified skin risk and actual wound development, leading to a deficiency in care for the resident.
Failure to Set Parameters for As-Needed Diuretic Medication
Penalty
Summary
The facility failed to establish parameters for administering as-needed diuretic medication based on weight gain for a resident with severe cognitive impairment and a diagnosis of acute systolic congestive heart failure. The resident's medical record included an order for furosemide, a diuretic, to be given as needed for weight gain, but lacked specific instructions on the amount of weight gain required before administration. Additionally, the resident's care plan did not address the use of diuretic medication, daily weight monitoring, or the heart failure diagnosis. Interviews with an LPN and the DON confirmed the absence of these critical instructions and care plans.
Infection Control Breach During Dressing Change
Penalty
Summary
The facility failed to maintain proper infection control procedures during a dressing change for a resident with pressure ulcers. The resident, who was admitted with diagnoses including multiple sclerosis, paraplegia, peripheral vascular disease, and anxiety, had an intact cognition and used a wheelchair for mobility. The resident had an indwelling suprapubic urinary catheter and was always incontinent of bowel. The physician's orders required specific wound care for the coccyx area, including cleansing with wound cleanser, applying medihoney, and covering with a silicone dressing. During an observation of the dressing change, an LPN washed her hands and donned gloves to remove the old dressing. After removing her gloves, she washed her hands, but subsequently failed to wash her hands between subsequent glove changes. This occurred when she cleansed the wound, applied medihoney, and assisted with replacing the resident's incontinence brief. The LPN confirmed in an interview that she did not wash her hands between glove changes, which was against the facility's wound care policy that required handwashing after removing disposable gloves.
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 225 citations issued within 25 miles in the last 12 months — including the 4 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 New Lexington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Altercare Somerset Inc. | 8.1 mi | ★★★★★ | 12 | 0 |
| Country Lane Gardens Rehab & Nursing Ctr | 14.5 mi | ★★★★★ | 49 | 3 |
| Embassy Of Logan | 15.1 mi | ★★★★★ | 12 | 0 |
| Altercare Thornville Inc. | 17.8 mi | ★★★★★ | 13 | 1 |
| Buckeye Care And Rehabilitation | 18.7 mi | ★★★★★ | 23 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Majestic Care Of New Lexington.
100% money-back within 48 hours.
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.