Majestic Care of Newburgh

In the surveyor’s words

From the most serious findings on record at Majestic Care of Newburgh, in the surveyor’s own words.

• Actual harm, isolatedF690May 9, 2024

  Based on interview and record review, the failed to ensure a resident who entered the facility with an indwelling urinary catheter was effectively assessed for adverse outcomes of an indwelling urinary catheter, received treatment and services to prevent infection in accordance with the physician orders and the plan of care, or was effectively monitored for complications of bloody urine after the catheter was suspected to be pulled for 1 of 4 residents reviewed for urinary catheters. This deficient practice resulted in Resident 35 being hospitalized for the treatment of urethral obstruction and sepsis. (Resident 35) Finding includes: On 5/2/24 at 9:30 A.M., a family member indicated Resident 35 had been admitted to the hospital with sepsis due to a UTI (urinary tract infection). […]

• No harm, potential for more than minimal, widespreadF812Jul 3, 2025

  Based on observation, interview, and record review, the facility failed to ensure the dishwasher was sanitizing dishes properly and staff knew how to properly test for sanitization for 1 of 1 kitchens in the facility. (Kitchen) Finding includes: During an observation on 6/29/25 at 8:15 A.M., the Kitchen Manager ran a dishwasher cycle. The wash cycle reached 155 degrees Fahrenheit (F), the rinse cycle reached 138 degrees F, and the sanitization level on the chlorine test strips read zero parts per million (ppm). The Kitchen Manager indicated the dishwasher was a low temperature dishwasher and the dishwasher sanitization had been testing fine the night before. Kitchen staff continued to put dishes through the dishwasher. […]

• No harm, potential for more than minimal, patternF677Jul 3, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents dependent on staff for assistance with activities of daily living (ADL) tasks were provided showers or baths for 4 of 5 residents reviewed for ADL care. (Resident 27, Resident 97, Resident 11, and Resident 36) Findings include: 1. During an interview on 6/29/25 at 9:37 A.M., Resident 27 indicated he hadn't had any baths lately. Resident 27 had a strong, pungent smell surrounding him. On 6/30/25 at 10:06 A.M., Resident 27's clinical record was reviewed. Resident 27 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, diabetes mellitus. […]

• No harm, potential for more than minimal, patternF761Jul 3, 2025

  Based on observation, interview, and record review, the facility failed to ensure medications were properly stored and labeled for 4 of 5 medication carts reviewed and 1 treatment cart reviewed. (100 Hall Cart 1, 100 Hall Cart 2, 200 Hall Cart 1, 200 Hall Cart 2, 100 Hall Treatment Cart) Findings include: 1. On 6/29/25 at 8:00 A.M., the following loose pills and liquid medications were observed in 100 Hall Cart 1: 1 oblong white pill with numbers 1222 1 round white pill with the letter AM and numbers 520 1 blue oblong pill with letter ARI and number 5 1 small round peach pill 1 small round white pills with the number 15 1 large brown capsule 1 round white pill with the number 745 1 oval white pill with the number 22 1 small round white pill 1/2 small round white pill 1 small round peach… […]

• No harm, potential for more than minimal, patternF880Jul 3, 2025

  Based on observation, interview, and record review, the facility failed to ensure infection prevention practices were implemented during laundry services during 1 of 1 observations of laundry services. (Laundry Room) Finding includes: During an observation on 7/1/25 at 11:12 A.M., the Corporate Manager emptied the washer without wearing an apron and items in the washer were placed against her shirt and top of pants as well as her arms. During an interview on 7/3/25 at 9:22 A.M., the Director of Nursing indicated that when staff transferred clean laundry they should ensure laundry was not touching their uniforms. […]