Inspection·April 1, 2025

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** Based on interviews, record reviews, and facility validation accessing implanted vascular access port guidelines the facility failed to ensure an antibiotic was ordered correctly and an implanted vascular access port (port a cath) was accessed with a physician's order. This affected one resident (#11) of two residents reviewed for indwelling devices and antibiotics. The facility census was 56. Residents Affected - Few Findings include: Review of the medical record for Resident #11, revealed an admission date of 02/12/25 and a was sent to the hospital when at Fairfield Healthcare Professional Hematology and Oncology infusion appointment on 03/07/25. Diagnoses included but were not limited to partial intestinal obstruction, malignant neoplasm of colon, moderate protein-calorie malnutrition, osteoarthritis, iron deficient anemia, essential hypertension and personal history of venous thrombosis and embolism. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15. The resident was assessed to require setup or clean-up assistance with eating, oral hygiene, toilet hygiene, shower/bathe self, and supervision or touching assistance with bed mobility and transfers. This resident was also assessed to be occasionally incontinent or bladder and bowel elimination. Review of the hospital discharge paperwork dated 02/12/25 revealed Resident #11 had an implanted vascular access port to her left upper chest. Review of the facility admission assessment dated [DATE] revealed Resident #11's implanted vascular access port was not accessed. Review of the plan of care for Resident #11 revealed no focus, goal and interventions for the un accessed implanted vascular access port. Review of the physician's order dated 03/06/25 at 5:22 P.M. entered by Registered Nurse (RN) #323 revealed Cefepime Hydrochloric Acid (HCL) intravenous solution reconstituted 2 grams, use 2 grams intravenously two times a day for bacteremia until 03/18/25 telephone order from Physician #222. Review of the progress note dated 03/07/25 at 6:10 A.M. authored by RN #420 revealed a Huber needle 20 gauge by 1 inch accessed to left upper chest per sterile procedure. Port a cath flushed with blood return from cath. Resident tolerated procedure well. Intravenous (IV) antibiotics started. Review of the Medication Administration Record dated 03/07/25 at 7:00 A.M. revealed Resident #11 (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 4 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 04/01/2025 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)