Inspection·March 26, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and review of the AccuWeather forecast the facility failed to ensure Resident #29's window was shut during cold weather. This affected one resident (#29) of three sampled residents reviewed. The facility census was 60. Findings Include: Review of the medical record for Resident #29 revealed an initial admission date of 06/08/19 with the latest readmission of 02/12/24 with diagnoses including fracture of lower end of right ulna, pneumonitis due to inhalation of food and vomit, acute respiratory failure with hypoxia, metabolic encephalopathy, multiple sclerosis (MS), dysphagia, osteoarthritis, dry eye syndrome, hyperlipidemia, chronic pain syndrome, scoliosis, insomnia, hypothyroidism, major depressive disorder, repeated falls, anxiety disorder and constipation. Review of the resident's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had unclear speech, usually made herself understood, usually understood others, and had severe cognitive deficit. The resident was dependent on staff for activities of daily living (ADL). Review of Resident #29's care revealed no care plan addressing the resident's desire to have the window open. Review of the progress note dated 03/26/24 at 2:55 A.M., authored by Registered Nurse (RN) #124 revealed Resident #29 had yelled out frequently throughout the night and was on her call light. The resident was unable to accurately state what she needed but would frequently state, Yes or Right, when asked a question. The resident had been repositioned frequently, changed, given fluids, offered a snack and accepted, opened the room window and air conditioning (AC) turned on. The resident was also given as needed pain medication. On 03/26/24 at 9:52 A.M., observation of Resident #29 revealed Resident #29's window was open with the curtain blowing outward. The resident's heating/cooling unit was noted to be on and blowing cold air. Interview with Resident #29 at the time of the observation revealed the resident stated, freezing. On 03/26/24 at 9:55 A.M., interview with State Tested Nursing Assistant (STNA) #134 verified the window and the resident's air conditioning was on. The STNA verified the room was cold. Review of the AccuWeather forecast for 03/25/24 into the morning of 03/26/24 revealed the low (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 2 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 03/26/2024 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)