Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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.
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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.
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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 | — | 11 | 0 |
| Country Lane Gardens Rehab & Nursing Ctr | 14.5 mi | — | 35 | 3 |
| Embassy Of Logan | 15.1 mi | — | 3 | 0 |
| Altercare Thornville Inc. | 17.8 mi | — | 7 | 0 |
| Buckeye Care And Rehabilitation | 18.7 mi | — | 21 | 0 |
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