Health inspection·June 5, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and staff interview, the facility failed to ensure a safe, functional, and homelike environment for the residents. This affected three (Residents #54, #81 and #116) of the three residents reviewed for a homelike environment. The facility census was 148. Findings include: Observation of the resident rooms on 06/04/25 from 1:10 P.M. to 1:22 P.M. with Maintenance Director #510 revealed the following: a) Resident #54's room had a damaged, brown and black discolored ceiling tile above the resident's bed. b) Resident #81's room had three damaged, brown and black discolored ceiling tiles above the resident's bed, one broken ceiling tile with a portion of the ceiling tile missing, and one entire ceiling tile, approximately three feet by four feet that was missing. c) Resident #116's room had three damaged, brown and black discolored ceiling tiles above the resident's bed. Interview on 06/04/25 at 1:22 P.M. with Maintenance Director #510, verified Residents #54, #81 and #116's room conditions. Page 1 of 7 365209 365209 06/05/2025 Majestic Care of Middletown LLC 6898 Hamilton Middletown Road Middletown, OH 45044

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to nail care for residents. This affected two (Residents #32 and #100) of three residents reviewed for care and services. The facility census was 148. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses of Alzheimer's dementia, Parkinson's disease, diabetes mellitus type II, bipolar disorder and psychotic disorder. Review of the Minimum Data Set (MDS) significant change assessment dated [DATE] revealed Resident #32 had significant cognitive impairment and was always incontinent of bowel and bladder. The resident required set up assistance with eating, oral and personal hygiene, maximal assistance with bed mobility and was dependent for toileting, bathing, dressing and transfers. During an observation on 06/02/25 at 4:33 P.M., Resident #32 was sitting in her wheelchair at the overbed table dressed in clean and seasonal appropriate personal clothing. All the resident's fingernails were long and jagged with an unknown material under the nails. Interview with the resident was attempted, but not possible due to the resident's cognitive impairment. 2. Review of the medical record revealed Resident #100 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus type II, rhabdomyolysis, rib fracture (one), metabolic encephalopathy and alcohol dependence. Review of the Minimum Data Set (MDS) Medicare five-day assessment dated [DATE] revealed Resident #100 had moderate cognitive impairment and was always continent of bowel and occasionally incontinent of bladder. The resident required set up assistance with eating, supervision with oral hygiene and bed mobility and moderate assistance with toileting, bathing, dressing and transfers. During an observation on 06/02/25 at 5:25 P.M., Resident #100 revealed resident sitting in his wheelchair at the overbed table eating supper and watching television, dressed in clean and seasonal appropriate personal clothing. All the resident's fingernails were long and jagged with an unknown material under the nails. During an interview at the time of the observation, Resident #100 stated he would like nail care to be completed by the nursing staff. During an observation and subsequent interview on 06/03/25 at 1:22 P.M., the Director of Nursing (DON) verified the fingernails of Residents #32 and #100 were long, jagged, dirty and in need of care. 365209 Page 2 of 7 365209 06/05/2025 Majestic Care of Middletown LLC 6898 Hamilton Middletown Road Middletown, OH 45044

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review and staff interview, the facility failed to followed ordered pharmacy recommendations. This affected one (Resident #135) of five residents review for unnecessary medications. The census was 148. Findings include: Review of Resident #135's medical record revealed an admission date of 11/15/24. Diagnoses listed included tremors, anemia, depression, chronic pain syndrome, thrombocytopenia, anxiety, tracheostomy, and type two diabetes mellitus. Review of a pharmacy recommendation dated 04/08/25 revealed a recommendation was made for as needed (PRN) Narcan (narcotic reversal medication) to be on hand due to Resident #135 having current orders for an opioid (Oxycodone) along with a benzodiazepine (Clonazepam). This combination increases the risk of life-threatening overdose. The pharmacy recommendation was documented as accepted with a verbal order from physician. Review of physician orders revealed Narcan PRN was not ordered for Resident #135 until 06/04/25. During an interview on 06/05/28 at 8:18 A.M. the Director of Nursing (DON) confirmed PRN Narcan was not ordered until 06/04/25. The DON confirmed PRN Narcan was not ordered timely and was not ordered until Resident #135's pharmacy recommendations were requested. 365209 Page 3 of 7 365209 06/05/2025 Majestic Care of Middletown LLC 6898 Hamilton Middletown Road Middletown, OH 45044

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, record review, staff interviews, and policy review, the facility failed to ensure insulin vials were properly labeled and stored. This affected three (Residents #23, #29 and #128) of the 26 residents with medications stored in the Aspen medication cart. The facility census was 148. Findings include: During an observation of the Aspen medication cart on 06/04/25 at 8:48 A.M., Licensed Practical Nurse (LPN) #521 found Resident #23's Lantus insulin pen-injector was not dated when removed from the refrigerator and placed in the medication cart for administration; Resident #29's Glargine insulin pen-injector was not dated when removed from the refrigerator and placed in the medication cart for administration; and Resident #128's Tresiba pen-injector was not dated when removed from the refrigerator and placed in the medication cart for administration. During an interview at the time of the observation, LPN #521 verified none of the pens were dated when removed from stock. During an interview on 06/04/25 at 9:04 A.M, the Director of Nursing verified insulin vials and insulin pen-injectors are to be dated when removed from the refrigerator and placed in the medication cart for administration. During an interview on 06/05/25 at 2:43 P.M., Consulting Pharmacist #900 verified insulin vials/pen-injectors are to be dated when removed from refrigerated storage and placed in the medication cart for use. Review of the policy titled, Storage of Medications, revised August 2020, revealed certain medications or package types, such as intravenous (IV) solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, and blood sugar testing solutions and strips require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency. 365209 Page 4 of 7 365209 06/05/2025 Majestic Care of Middletown LLC 6898 Hamilton Middletown Road Middletown, OH 45044

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and policy review, the facility failed to ensure food storage areas were clean and food items were store appropriately. This had the potential to affect all residents that eat food from the kitchen. The facility identified eight (Residents #57, #89, #92, #101, #108, #122, #134, and #139) residents that did not eat food from the kitchen. The facility also failed to ensure resident refrigerators were clean. This affected Resident #36. The census was 148. Findings include: 1. During an observation on 06/02/25 at 9:03 A.M., the refrigerator in the kitchen had food storage shelves were dirty and covered in debris. The shelves had spots of a blackish green substance. Several milk cartons were in a plastic tub in the refrigerator. The milk cartons were sitting in water. No ice was in the tub. 2. During an observation 06/02/25 at 9:08 A.M., the dry storage area in the kitchen had a large plastic container containing dry cereal that was on a roll cart. The container did not have a lid. A rubber floor mat was near the cart was above the level of the cereal. The room as dirty and the floor was covered in debris. Several plastic bowls containing dry cereal were on the cart. The bowls were not labeled or dated. During an interview on 06/02/25 at 9:11 A.M., Dietary Manager (DM) #610 confirmed the above observations. 3. During an observation on 06/02/25 at 10:30 A.M., Resident #36's refrigerator had spilled cranberry juice in the bottom of the refrigerator with multiple dead, black bugs in the spilled juice. During an interview at the time of the observation, Certified Nursing Assistant (CNA) #513 verified the above observation. spilled cranberry juice and dead bugs in the refrigerator in the room of Resident #36. Review of the facility policy titled, Food Storage: Dry Goods, dated 2023, revealed storage areas will be neat, arranged for easy identification, and date marked as appropriate. Review of the facility policy titled, Food Storage: Cold Foods, revised February 2023, revealed all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the facility policy titled, Environment, revised September 2017, revealed all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. All food contact surfaces will be cleaned and sanitized after each use. 365209 Page 5 of 7 365209 06/05/2025 Majestic Care of Middletown LLC 6898 Hamilton Middletown Road Middletown, OH 45044

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and policy review, the facility failed to have a Legionella prevention program. This had the potential to affect all residents of the facility. The facility also failed to to ensure staff changed gloves and washed their hands appropriately during incontinence care. This affected one (Resident #97) of three residents reviewed for incontinence. The census was 148. Residents Affected - Many Findings include: 1. Review of the facility's water management documentation revealed no evidence of an implemented Legionella prevention plan. There was no documentation of any members designated to manage a Legionella prevention plan. There was no documentation of any control measures being put in place to prevent Legionella. During an interview on 06/04/25 at 3:35 P.M., Maintenance Supervisor (MS) #496 and the Administrator stated there was not an implemented Legionella prevention plan. MS #496 confirmed there was no documentation of any control measures in place to prevent Legionella. Review of the facility's policy titled Water Management Program, dated 05/15/25, revealed the water management program (WMP) is-a multi-faceted process designed to reduce the growth and spread of opportunistic bacteria. The WMP includes developing a team, describing building water systems, identifying areas or devices where opportunistic bacteria such as Legionella might grow or spread to people, control measures, and remediation interventions when control measures are not met. 2. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of intracerebral hemorrhage, hemiplegia and hemiparesis, morbid (severe) obesity, encephalopathy and depression. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #19 had no cognitive impairment, range of motion impairments on one side, upper and lower extremities and was always incontinent of bowel and bladder. The resident required set up assistance for eating, dependent for dressing and maximal assistance for oral and personal hygiene, toileting, bathing, bed mobility and transfers. Review of physician orders for Resident #97 revealed an order dated 01/01/25 to cleanse the suprapubic catheter site with soap and water and apply a drain sponge every shift. During an observation on 06/03/25 at 4:25 P.M., Resident #97, who was under Enhanced Barrier Precautions (EBP), received catheter care and incontinence care in bed from Certified Nursing Assistant (CNA) #541. The resident was provided with catheter care and then bowel incontinence care. After catheter care and bowel incontinence care was provided, CNA #541, still wearing the gloves to provide catheter and incontinence care, touched the bathroom doorknob, bathroom sink faucet, applied a clean brief, pulled the resident's pajama bottoms up, and touched the wheelchair handles to move the wheelchair to the resident's bedside. CNA #541 doffed the gown and dirty gloves and left the room without washing and/or sanitizing her hands. Review of the EBP signage posted near the door to the room of Resident #97 revealed everyone must clean their hands, including before entering and when leaving the room. 365209 Page 6 of 7 365209 06/05/2025 Majestic Care of Middletown LLC 6898 Hamilton Middletown Road Middletown, OH 45044

F 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 01/22/25 at 2:55 P.M., CNA #541 verified she did not change her gloves after completing incontinence care and before she touched the bathroom doorknob, bathroom sink faucet handle, application of clean brief on resident, pulling the resident's pajama bottoms up and touching the resident's wheelchair handles. She also verified she did not sanitize and/or wash her hands before leaving the resident's room. Residents Affected - Many Review of the policy titled, Enhanced Barrier Precautions, dated 03/20/24, revealed it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Review of the policy titled, Handwashing-Hand Hygiene, revised 03/05/25, revealed the purpose of the policy and procedure was to prevent the spread of infections through proper hand hygiene. Care team members must wash their hands for twenty (20) seconds using antimicrobial or non-microbial soap and water or use of an alcohol-based hand rub before and after direct contact with residents and after removing gloves. This deficiency represents non-compliance investigated under Complaint Number OH00164818. 365209 Page 7 of 7