Inspection visit
Inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0561
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to and the facility must promote and facilitate resident self-determination through
support of resident choice.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, record review and Ohio Revised Code review, the facility failed to ensure a resident was
permitted to choose his Power of Attorney (POA) and failed to ensure POA paperwork was legal. This
affected one resident (#63) of three residents reviewed for POA concerns. The facility census was 60.
Findings included:
Review of Resident #63's closed medical record revealed an admission date of [DATE] with diagnoses
including chronic kidney disease, stage 3 B, mild cognitive impairment of uncertain or unknown etiology,
urine retention, and essential hypertension. He expired in the facility on [DATE].
Review of Resident #63's admission Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed he
was cognitively impaired.
Review of Resident #63's Clinical Resident Profile revealed Licensed Practical Nurse (LPN) #2 was his
POA.
Review of Resident #63's State of Ohio Health Care Power of Attorney, dated [DATE], revealed it was
signed by the Principal (Resident #63) and witnessed by LPN #1 providing LPN #2 legal POA.
Review of Resident #63's progress note, dated [DATE] and timed 2:46 P.M. revealed the Social Services
Designee (SSD) #3 had a meeting with Ombudsman #9 and Resident #63's family. Ombudsman #9
revealed Resident #63 wanted Friend #10 to be his POA as Resident #63 had stated that was his choice.
Telephone interview on [DATE] at 8:29 A.M. with the facility Ombudsman #9 revealed Resident #63 had told
her several times he did not want LPN #2 to be his POA.
Interview on [DATE] at 9:22 A.M. with SSD #3 revealed since Resident #63's admission, he had wanted
Friend #10 to be his POA. SSD #3 revealed when she spoke with Resident #63, he was lucid enough to
make choices regarding POA. SSD #3 revealed Resident #63 did not want LPN #2, who was his
stepdaughter from a marriage that ended thirty years ago, to be his POA. SSD #3 reported facility staff
were not to be resident POAs, unless they met the requirements, or witnesses for legal documents. SSD #3
reported Friend #10 had been taking care of Resident #63's check book and was paying his bills. SSD #3
revealed she reviewed Resident #63's bank statements due to working on a plan for Medicaid for him and
there was no sign of Friend #10 misusing his funds. SSD #3 revealed Resident #63 did not present with any
mental anguish due to not having Friend #10 as his POA.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 10
Event ID:
365578
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365578
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Majestic Care of New Lexington
920 South Main Street
New Lexington, OH 43764
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0561
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview on [DATE] at 10:12 A.M. with Regional Support Administration #7 verified the facility did not have
a policy regarding POAs, but even though the facility did not have a policy regarding staff witnessing legal
documents, it is best practice for facility staff to not be the witness for legal documents.
Interview on [DATE] at 10:20 A.M. with LPN #1, after reviewing the POA dated [DATE] and witnessed by
LPN #1, revealed she did remember signing the POA form for Resident #63. LPN #1 reported she was at
the unit one nursing station when LPN #2 brought the POA form to her. LPN #1 revealed she did not
witness Resident #63 sign the POA and reported she did not know she was signing as a witness to
Resident #63's signature because she had never been asked to do that before. She thought she was
signing the form on behalf of Resident #63's physician and per his directive. LPN #1 reported she did not
know what LPN #2 told Resident #63 prior to him signing the form or if the signature on the POA was
Resident #63's signature.
Review of Ohio Revised Code Section 1337.12, Formality of execution, effective [DATE], revealed under
(A)(2) except as otherwise provided in this division, durable power of attorney for health care may designate
any competent adult as the attorney in fact. The attending physician of the principal and an administrator of
any nursing home in which the principal is receiving care shall not be designated as an attorney in fact in,
or act as an attorney in fact pursuant to, a durable power of attorney for healthcare. An employee or agent
of the attending physician of the principal and an employee or agent of any health care facility in which the
principal is being treated shall not be designated as an attorney in fact in, or act as an attorney in fact
pursuant to, a durable power of attorney for health care, except that these limitations do not preclude a
principal from designating either type of employee or agent as the principal's attorney in fact if the individual
is a competent adult and related to the principal by blood, marriage, or adoption, or if the individual is a
competent adult and the principal and the individual are members of the same religious order.
This deficiency represents non-compliance investigated under Complaint Number OH00147414.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365578
If continuation sheet
Page 2 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365578
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Majestic Care of New Lexington
920 South Main Street
New Lexington, OH 43764
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE
FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS
SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Residents Affected - Few
Based on record review, interview, and facility policy review, the facility failed to ensure vascular wounds
were properly assessed, treatments were completed as ordered by the physician, and a care plan was
developed for his vascular wounds to meet the resident needs. This affected one resident (#63) of three
residents reviewed for wounds. The facility census was 60.
Findings included:
Review of Resident #63's medical record revealed an admission date of [DATE] with diagnoses including
chronic kidney disease, stage 3 B, mild cognitive impairment of uncertain or unknown etiology, urine
retention, and essential hypertension. He expired in the facility on [DATE].
Review of Resident #63's admission Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed he
was cognitively impaired. Further review also revealed he did not have any venous or arterial ulcers and no
other skin issues.
Review of Resident #63's Baseline Care Plan, dated [DATE], revealed he had an alteration in his skin
integrity on his right great toe and scattered scabs to bilateral lower extremities.
1. Right Great Toe:
a. Assessment
Review of Resident #63's Skin Grid Non-Pressure document, dated [DATE], revealed the area was first
observed on admission on [DATE] and was a callous like area measuring 1.5 centimeters (cm) x 1.0 cm x
0.1 cm.
The next Skin Grid Non-Pressure document for the right great toe, dated [DATE], revealed the area was
first observed on admission on [DATE] and remained a callous like area measuring 1.5 centimeters (cm) x
1.0 cm x 0.1 cm.
The next Skin Grid Non-Pressure document for the right great toe, dated [DATE], revealed the areas was
first observed on admission on [DATE] and revealed there were two open areas on the right great toe: one
on the top of the toe measuring 2.0 cm x 2.0 cm and one on the tip of the toe measuring 2.5 cm x 3 cm.
Interview on [DATE] at 10:23 A.M. with the Regional Registered Nurse (RRN) #11 and the Director of
Nursing (DON) verified Resident #63 did not have documentation to support his right great toe was
assessed weekly between [DATE] and [DATE] and between [DATE] and [DATE] and it should have been.
b. Treatment
Review of Resident #63's physician order, dated [DATE] to [DATE], identified his right great toe was to be
cleaned with wound cleaner, patted dry, and painted with betadine until resolved.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365578
If continuation sheet
Page 3 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365578
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Majestic Care of New Lexington
920 South Main Street
New Lexington, OH 43764
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of Resident #63's [DATE] Treatment Administration Record (TAR) revealed no documentation to
support he received his physician ordered treatment of cleanse right great toe with wound cleanser, pat dry,
and paint with betadine until resolved on day shift on [DATE], [DATE], and [DATE].
Review of Resident #63's [DATE] TAR revealed no documentation to support he received his physician
ordered treatment of cleanse right great toe with wound cleanser, pat dry, and paint with betadine until
resolved on day shift on [DATE].
Interview on [DATE] at 10:23 A.M. with the DON verified Resident #63 did not have documentation to
support his right great toe received treatments on [DATE], [DATE], [DATE], and [DATE] as ordered by the
physician.
2. Right Second Toe
a. Assessments
Review of Resident #63's Skin Grid Non-Pressure document for the right second toe, dated [DATE],
revealed an area first observed on [DATE] and it was an open area noted to the second digit of the right
foot. There was no documentation to support the size of the wound.
The next Skin Grid Non-Pressure document for the right second toe, dated [DATE], revealed an area first
observed on [DATE] and it was an open area noted to the second digit of the right foot. Documentation on
the form revealed the size of the wound was 1.5 cm x 1.0 cm x 0.1 cm. This was the last documented Skin
Grid Non-Pressure document for the right second toe.
Interview on [DATE] at 10:23 A.M. with the RRN #11 and the DON verified there should have been
additional Skin Grid Non-Pressure documentation due the documentation on [DATE] did not reveal the
wound was healed.
Interview on [DATE] at 3:35 P.M. with the DON verified the [DATE] Skin Grid Non-Pressure documentation
should have included the size of the wound.
b. Treatment
Review of Resident #63's physician order, dated [DATE] to [DATE], identified he was to have the second
digit on his right foot cleaned with wound cleanser, patted dry, calcium alginate applied daily and covered
with a clean dry dressing daily and as needed until resolved.
Review of Resident #63's [DATE] TAR revealed no documentation to support he received his physician
ordered treatment of cleanse second digit to the right foot with wound cleanser, pat dry, apply calcium
alginate daily and cover with dry clean dressing and as needed until resolved on day shift on [DATE].
Review of Resident #63's [DATE] TAR revealed no documentation to support he received his physician
ordered treatment of cleanse second digit to the right foot with wound cleanser, pat dry, apply calcium
alginate daily and cover with dry clean dressing and as needed until resolved on day shift on [DATE] or
[DATE].
Review of Resident #63's physician order, dated [DATE] to [DATE], identified he was to have the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365578
If continuation sheet
Page 4 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365578
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Majestic Care of New Lexington
920 South Main Street
New Lexington, OH 43764
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
second digit on his right foot cleaned with wound cleanser, patted dry, and painted with betadine daily and
as needed until resolved. This order started on [DATE].
Review of Resident #63's [DATE] TAR revealed no documentation to support he received his physician
ordered treatment of cleanse second digit of the right foot with wound cleanser, pat dry, paint with betadine
daily and as needed until resolved on day shift on [DATE].
Interview on [DATE] at 10:23 A.M. with the DON verified Resident #63 did not have documentation to
support his right second toe received treatments on 06/27, [DATE], [DATE], or [DATE] as ordered by the
physician.
3. Left Great Toe:
a. Treatment
Review of Resident #63's physician order, dated [DATE] to [DATE], identified his left great toe bony
prominence areas was to have betadine applied every shift and as needed until resolved.
Review of Resident #63's [DATE] TAR revealed no documentation to support he received his physician
ordered treatment of apply betadine to the left great toe bony prominence area every shift and as needed
until resolved on day shift on [DATE].
Review of Resident #63's [DATE] TAR revealed no documentation to support he received his physician
ordered treatment of apply betadine to the left great toe bony prominence area every shift and as needed
until resolved on day shift on [DATE].
Review of Resident #63's [DATE] TAR revealed no documentation to support he received his physician
ordered treatment for applying betadine to left great toe bony prominence area every shift and as needed
until resolved on night shift on [DATE].
Interview on [DATE] at 10:23 A.M. with the DON verified Resident #63 did not have documentation to
support his left great toe received treatments on 06/27, [DATE], or [DATE] as ordered by the physician.
4. Review of Resident #63's plan of care revealed no focus, goals or interventions for vascular wounds until
[DATE].
Interview on [DATE] at 3:40 P.M. with the DON verified Resident #63 did not have any plan of care for
vascular wounds until [DATE] when he should have been care planned for vascular wounds from admission
due to the right great toe skin concern was noted on admission.
Review of the facility policy titled, Wound Management Program, undated, revealed under the section of
ongoing wound assessment that a system for pressure injury assessment and documentation with each
dressing change or at least weekly is established. Further review under the section of wound management
principles revealed wound management principles included maintaining a physiologic local wound
environment, including (but not limited to) preventing and managing infection, cleansing wound, removing
nonviable tissue, managing exudate, eliminating dead space, controlling odors, protecting the wound and
managing pain. Additionally, the policy revealed under the section of documentation and care planning
additional documentation requirements of the wound management program include
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365578
If continuation sheet
Page 5 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365578
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Majestic Care of New Lexington
920 South Main Street
New Lexington, OH 43764
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
individualized care plans which were to be completed upon admission and updated on an ongoing basis.
Level of Harm - Minimal harm
or potential for actual harm
The deficiency was corrected on [DATE] after the facility implemented the following corrective actions:
•
Residents Affected - Few
On [DATE] the Regional Registered Nurse (RN) #11 completed one to one education with Licensed
Practical Nurse (LPN) #8 regarding: the facility wound care policy, facility wound management policy, facility
wound protocols, National Pressure Ulcer Advisory Panel Staging Guidelines, Pressure verses
Non-Pressure, documentation, care planning related to wounds, completing skin grids (assessments) every
seven days, providing nutritional supplements to help promote wound healing and steps to take when new
skin areas area discovered.
•
On [DATE] LPN #8 had completed new skin grids accurately and thoroughly (including correct location/site,
correct type of wound, correct stage if appropriate), ensured appropriate treatments were in place, and
ensured care plans were updated on all in-house residents with current wounds.
•
On [DATE] the Regional RN #11 completed nurse initiated education with all nursing staff regarding the
facility wound care policy, facility wound management policy, and steps to take when new skin areas are
discovered.
•
On [DATE] the facility DON or designee initiated weekly audits for four weeks to ensure the Wound
Management Program was followed and the deficiency was documented in the Quality Assurance and
Performance Improvement program.
•
On [DATE] at 9:55 A.M., (during the onsite survey) interview with LPN #8 (wound nurse) revealed she had
recently been educated on proper wound assessments, wound grids being done weekly, wound grids being
completed accurately, proper treatments for wounds and care planning for wounds.
•
On [DATE], during the onsite survey, review of facility documentation including completion of skin/wound
audits, revealed the facility had implemented their correction actions.
This deficiency is cited as an incidental finding to Complaint Number OH00147414.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365578
If continuation sheet
Page 6 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365578
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Majestic Care of New Lexington
920 South Main Street
New Lexington, OH 43764
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE
FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS
SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Residents Affected - Few
Based on record review, interview and facility policy review, the facility failed to ensure pressure ulcer
treatments were completed as ordered by the physician and a care plan was developed to meet the
resident needs. This affected one resident (#63) of three residents reviewed for wounds. The facility census
was 60.
Findings included:
Review of Resident #63's closed medical record revealed an admission date of [DATE] with diagnoses
including chronic kidney disease, stage 3 B, mild cognitive impairment of uncertain or unknown etiology,
urine retention, and essential hypertension. He expired in the facility on [DATE].
Review of Resident #63's admission Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed he
was cognitively impaired. Further review also revealed he did not have any pressure ulcers and no other
skin issues.
Review of Resident #63's Skin Grid Pressure, dated [DATE], revealed he had a pressure ulcer to his right
heel measuring 1.5 centimeters (cm) x 1.5 cm and a pressure ulcer to his left heel measure 3.0 cm x 3.0
cm.
1. Right Heel Treatments
Review of Resident #63's physician orders revealed the following regarding treatment to her right heel:
order dated, [DATE] to [DATE], identified his right heel was to be cleansed with normal saline, patted dry,
calcium alginate applied, covered with a 4 x 4 gauze, covered with foam dressing daily and as needed;
order dated, [DATE] to [DATE], identified his right heel was to be cleansed with normal saline, patted dry,
covered with Mepilex every day and as needed;
order dated, [DATE] to [DATE], identified his right heel was to be cleansed with normal saline, patted dry,
iodosorb, gauze applied, cupped ABD applied, kerlix applied, tubifast blue applied every day;
and order dated, [DATE] to [DATE], identified his right heel was to be dressed with iodosorb gauze, cupped
ABD applied, kerlix applied, and tubifast blue applied.
Review of Resident #63's [DATE] TAR revealed no documentation to support he received his old or newly
ordered physician ordered treatment on [DATE] or [DATE].
Interview on [DATE] at 10:23 A.M. with the Director of Nurses (DON) verified Resident #63 did not have
documentation to support his right heel received treatments on [DATE] or [DATE] as ordered by the
physician.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365578
If continuation sheet
Page 7 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365578
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Majestic Care of New Lexington
920 South Main Street
New Lexington, OH 43764
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
2. Left Heel Treatments
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident #63's physician orders revealed the following regarding treatment to her left heel:
Residents Affected - Few
order dated, [DATE] to [DATE], identified his left heel was to be cleansed with normal saline, patted dry,
calcium alginate applied, covered with a 4 X 4 gauze, covered with foam dressing daily and as needed;
order dated, [DATE] to [DATE], identified his left heel was to be cleansed with normal saline, patted dry,
covered with Mepilex every day and as needed;
order dated, [DATE] to [DATE], identified his left heel was to be cleansed with normal saline, patted dry,
iodosorb, gauze applied, cupped ABD applied, kerlix applied, tubifast blue applied every day;
and order dated, [DATE] to [DATE], identified his left heel was to be dressed with iodosorb gauze, cupped
ABD applied, kerlix applied, and tubifast blue applied.
Review of Resident #63's [DATE] TAR revealed no documentation to support he received his old or newly
ordered physician ordered treatment on [DATE] or [DATE].
Interview on [DATE] at 10:23 A.M. with the DON verified Resident #63 did not have documentation to
support his right heel received treatments on [DATE] or [DATE] as ordered by the physician.
3. Review of Resident #63's plan of care revealed no focus, goals or interventions for pressure ulcer
wounds until [DATE].
Interview on [DATE] at 3:40 P.M. with the DON verified Resident #63 did not have any plan of care for
pressure ulcer wounds until [DATE] when he should have been care planned for pressure ulcer wounds
shortly after [DATE] when the pressure ulcers to his bilateral heels were first noted.
Review of the facility policy titled, Wound Management Program, undated, revealed under the section of
wound management principles revealed wound management principles included maintaining a physiologic
local wound environment, including (but not limited to) preventing and managing infection, cleansing
wound, removing nonviable tissue, managing exudate, eliminating dead space, controlling odors, protecting
the wound and managing pain. Further review revealed under the section of documentation and care
planning additional documentation requirements of the wound management program include individualized
care plans which were to be completed upon admission and updated on an ongoing basis.
The deficiency was corrected on [DATE] after the facility implemented the following corrective actions:
•
On [DATE] the Regional Registered Nurse (RN) #11 completed one to one education with Licensed
Practical Nurse (LPN) #8 regarding: the facility wound care policy, facility wound management policy, facility
wound protocols, National Pressure Ulcer Advisory Panel Staging Guidelines, Pressure verses
Non-Pressure, documentation, care planning related to wounds, completing skin grids (assessments)
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365578
If continuation sheet
Page 8 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365578
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Majestic Care of New Lexington
920 South Main Street
New Lexington, OH 43764
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
every seven days, providing nutritional supplements to help promote wound healing and steps to take when
new skin areas area discovered.
•
On [DATE] LPN #8 had completed new skin grids accurately and thoroughly (including correct location/site,
correct type of wound, correct stage if appropriate), ensured appropriate treatments were in place, and
ensured care plans were updated on all in-house residents with current wounds.
•
On [DATE] the Regional RN #11 completed nurse initiated education with all nursing staff regarding the
facility wound care policy, facility wound management policy, and steps to take when new skin areas are
discovered.
•
On [DATE] the facility DON or designee initiated weekly audits for four weeks to ensure the Wound
Management Program was followed and the deficiency was documented in the Quality Assurance and
Performance Improvement program.
•
On [DATE] at 9:55 A.M., (during the onsite survey) interview with LPN #8 (wound nurse) revealed she had
recently been educated on proper wound assessments, wound grids being done weekly, wound grids being
completed accurately, proper treatments for wounds and care planning for wounds.
•
On [DATE], during the onsite survey, review of facility documentation including completion of skin/wound
audits, revealed the facility had implemented their correction actions.
This deficiency is cited as an incidental finding to Complaint Number OH00147414.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365578
If continuation sheet
Page 9 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365578
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Majestic Care of New Lexington
920 South Main Street
New Lexington, OH 43764
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, interview and facility policy review, the facility failed to ensure weights were obtained for a
new admission to the facility and failed to ensure weights were completed per physician order. This affected
one resident (#63) of three residents reviewed for weight loss. The facility census was 60.
Residents Affected - Few
Findings included:
Review of Resident #63's closed medical record revealed an admission date of [DATE] with diagnoses
including chronic kidney disease, stage 3 B, mild cognitive impairment of uncertain or unknown etiology,
urine retention, and essential hypertension. He expired in the facility on [DATE].
Review of Resident #63's admission Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed he
was cognitively impaired. He had no or unknown weight loss or gain and was on a therapeutic diet.
Review of Resident #63's weights revealed his first weight was completed on [DATE] and he weighed 174.2
pounds; his second weight was on [DATE] and he weighed 177.0 pounds, and his next weight was on
[DATE] and he weighed 167.8 pounds.
Interview on [DATE] at 8:16 A.M. with the Director of Nursing (DON) verified Resident #63 should have
been weighed upon admission or within three days and not five days after admission. She also verified he
did not have a weekly weight for the first month after admission and should have.
Review of the facility policy titled, Weight Policy, revised 05/2021 revealed under the section of routine
weights: weights will be obtained within 72 hours of admission then weekly for four weeks.
Review of Resident #63's physician orders, dated [DATE] and [DATE], identified he was to be weighed for
four weeks in the morning every Wednesday for monitoring related to trending weight loss until [DATE].
Based on these orders Resident #63 should have received weekly weights on [DATE], [DATE], [DATE], and
[DATE].
Review of Resident #63's plan of care, dated [DATE], revealed the resident had a nutritional problem or
potential for nutritional problem related to chronic disease, advanced age, pressure wounds, supplements,
therapeutic diet, and varying intake. One of the interventions included weigh resident as ordered.
Review of Resident #63's weights revealed no documented weights for [DATE] or [DATE] per the physician
order.
Interview on [DATE] at 10:25 A.M. with the DON verified Resident #63 did not have documented weights
per the physician order and should have been weighed on [DATE] and [DATE].
Review of the facility policy titled, Weight Policy, revised 05/2021, revealed under the section of weekly
weights: for residents being monitored on a weekly basis by the IDT (interdisciplinary team), weights are to
be obtained each week.
This deficiency was cited as an incidental finding to Complaint Number OH00147414.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365578
If continuation sheet
Page 10 of 10
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
FAQ · About this visit
Common questions about this visit
What happened during the November 3, 2023 survey of MAJESTIC CARE OF NEW LEXINGTON?
This was a inspection survey of MAJESTIC CARE OF NEW LEXINGTON on November 3, 2023. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MAJESTIC CARE OF NEW LEXINGTON on November 3, 2023?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to and the facility must promote and facilitate resident self-determination through support o..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.