Inspection·September 21, 2023

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Some #78 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require two-person total dependence with transfers, one-person extensive assistance with dressing and toileting, one-person limited assistance eating, and one-person total dependence with bathing. Review of the medical record for Resident #78 revealed she was sent to the hospital and admitted on [DATE] with no documentation of notification to the Ombudsman. 2. Review of the medical record for Resident #108 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: chronic respiratory failure, type two diabetes mellitus, end stage renal disease, stage three pressure ulcer to right and left buttock, unstageable pressure ulcer of left and right heel, and congestive heart failure. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #108 was not able to complete a Brief Interview for Mental Status (BIMS). This resident was assessed to require two-person total dependence with dressing and bathing, one-person total dependence with eating, two-person extensive assistance with toileting. Review of the medical record for Resident #108 revealed she was sent to the hospital and admitted on [DATE] and 08/24/23 with no documentation of notification to the Ombudsman. 3. Review of the medical record for Resident #131 revealed an admission date of 07/19/22. Diagnoses included pulmonary embolism, pneumonia, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and adjustment disorder with mixed anxiety and depressed mood. Review of the Significant Change MDS assessment dated [DATE] revealed this resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. This resident was assessed to require two-person extensive assistance with transfers and toileting, one-person extensive assistance with dressing and bathing, and supervision with eating. Review of the medical record for Resident #108 revealed he was sent to the hospital and admitted on [DATE] and 07/26/23 with no documentation of notification to the Ombudsman. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 2 of 20 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 365396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Fairfield LLC 5200 Camelot Drive Fairfield, OH 45014 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)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to accurately document on the Minimum Data Set (MDS) related to a residents bladder function. This affected one (#34) out of 31 residents reviewed for MDS. The facility census was 158. Residents Affected - Few Findings include: Review of the medical record for Resident #34 revealed an admission date of 06/12/21. Diagnoses included hypertensive heart disease with heart failure, atrial fibrillation, dementia, congestive heart failure, repeated falls, and history of urinary tract infections. Review of the Significant Change MDS assessment dated [DATE] revealed Resident #34 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of five. This resident was assessed to require one-person total dependence with dressing, one-person extensive assistance with eating, two-person extensive assistance with toileting, and two-person total dependence with bathing. Review of the MDS section H for bowel and bladder dated 08/12/23 revealed Resident #34 had an indwelling catheter. Urinary and bowel continence revealed Resident #34 was always incontinent. Review of the care plan dated 08/17/23 revealed Resident #34 at risk for infection/complications related to indwelling catheter related to urinary retention, obstructive and reflux uropathy. Interventions included assess quarterly and as needed for appropriateness of continued use of catheter. Staff to perform catheter care at least every shift and as needed. Staff to keep drainage bag and tubing below level of bladder. Staff to notify physician or abnormal findings. Staff to observe for signs of pain or discomfort related to catheter. Interview on 09/14/23 at 3:53 P.M. with MDS coordinator #344 verified MDS was coded incorrectly for urinary continence. MDS coordinator #344 reported some catheters leak and could be coded accordingly, but she stated Resident #34's did not leak and should had been marked as not assessed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 3 of 20 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 365396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Fairfield LLC 5200 Camelot Drive Fairfield, OH 45014 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interviews, and policy review, the facility failed to ensure care conferences were held with residents. This affected four (#03, #97, #108, and #145) of six residents reviewed for care conferences. The facility census was 158. Findings include: 1. Review of the medical record of Resident #03 revealed an admission date of 02/02/17. Diagnoses included chronic obstructive pulmonary disease (COPD), essential hypertension, hypothyroidism, bipolar disorder, peripheral vascular disease, major depressive disorder, and type 2 diabetes mellitus with diabetic neuropathy. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Interview on 09/11/23 at 1:00 P.M., Resident #03 stated the last time she had a care conference was approximately five years ago. Review of care conference notes revealed the resident had care conferences on 12/18/20 and 03/23/21. Interview on 09/13/23 at 12:47 P.M., Regional Nurse Consultant (RNC) #303 verified Resident #03 did not have a documented care conference since 03/21/21. 2. Review of the medical record for Resident #97 revealed an admission date of 08/19/20. Diagnoses included dementia, major depressive disorder, type two diabetes mellitus, chronic kidney disease stage 3B, and atrial fibrillation. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #97 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. This resident was assessed to require two-person total dependence with transfers, one-person extensive assistance with dressing, bathing, and toileting, and supervision with eating. Review of the care conference dated 02/07/23 revealed Resident #97 only had one care conference documented for the last 12 months. Interview on 09/13/23 at 12:47 P.M. with RNC #303 verified Resident #97 only had one care conference completed in the last 12 months which was on 02/07/23. 3. Review of the medical record for Resident #108 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: chronic respiratory failure, type two diabetes mellitus, end stage renal disease, stage three pressure ulcer to right and left buttock, unstageable pressure ulcer of left and right heel, and congestive heart failure. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #108 was not able to complete a BIMS. This resident was assessed to require two-person total dependence with dressing and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 4 of 20 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 365396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Fairfield LLC 5200 Camelot Drive Fairfield, OH 45014 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)

F 0657 bathing, one-person total dependence with eating, two-person extensive assistance with toileting. Level of Harm - Minimal harm or potential for actual harm Review of the care conference dated 04/13/23 revealed Resident #108 only had one care conference documented since admission. Residents Affected - Some Interview on 09/13/23 at 12:47 P.M. with RNC #303 verified Resident #108 only had one care conference completed since admission which was dated 04/14/23. 4. Review of the medical record for Resident #145 revealed an admission date of 03/24/23. Diagnoses included chronic obstructive pulmonary disease (COPD), emphysema, dementia, depression, and chronic respiratory failure with hypoxia. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #145 had moderate cognitive impairment as evidenced by a BIMS score of 10. This resident was assessed to require one-person limited assistance with transfers and eating, supervision with dressing, one-person extensive assistance with toileting, and one-person total dependence with bathing. Review of the care conference dated 03/28/23 revealed Resident #145 only had one care conference documented since admission. Interview on 09/13/23 at 12:47 P.M. with RNC #303 verified Resident #145 only had one care conference completed since admission which was dated 03/28/23. Review of the facility policy titled, Comprehensive Care Plans, dated 07/27/22, revealed the comprehensive care plan will be prepared by an interdisciplinary team (IDT) that includes the resident and the resident's representative (to the extent practicable) and reviewed and revised by the IDT after each comprehensive and quarterly MDS assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 5 of 20 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 365396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Fairfield LLC 5200 Camelot Drive Fairfield, OH 45014 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)

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** 2. Review of medical record revealed that Resident #16 had an admission date 05/18/23. Diagnoses included chronic obstructive pulmonary disease, Alzheimer's Disease, and hypertension. Residents Affected - Few Review of a MDS dated [DATE] that revealed Resident #16 had a Brief Interview for Mental Status (BIMS) of four out of 15 indicating she was severely cognitively impaired. Resident #16 required extensive two-person physical assist for bed mobility, toilet use, and bathing. Resident required extensive one-person physical assist for personal hygiene, eating, dressing, and transfers. Resident #16 was coded as always being incontinent of bowel and bladder. Review of plan of care dated 03/04/23 revealed Resident #16 was at risk for activity of daily living related to self-care performance deficit. Interventions included ace wraps to bilateral lower extremities wrap from toes to knees on in AM and off at bedtime, assist with eyeglasses, and transfers a two assist. Resident #16 was also at risk for potential injuries and falls related to impaired mobility, peripheral vascular disease, shortness of breath, anxiety, dementia, and Alzheimer's disease. Resident #16 had history of falls. Interventions included two-person assist with transfers, monitor safety and preventative devices for application, observe and report unsafe conditions, and a versa frame to toilet. Review of Continence/indwelling catheter evaluation dated 05/09/23 revealed that Resident #16 had bladder and bowel incontinence. Resident #16 was not aware she was wet. Observation on 09/12/23 at 10:54 A.M. with State Tested Nursing Assistant (STNA) #357 who came into dining room to get Resident #16 to take to hallway shower room down the hall to toilet resident. Resident #16 incontinent brief was moderate saturated with urine and had leaked through her pants. Interview on 09/12/23 at 11:10 A.M. with STNA #357 verified she changed her last before 8:30 A.M., but she did soak through her pants. 3. Review of medical record for Resident #149 revealed an admission date 05/12/23. Diagnoses included displace comminuted fracture of shaft of left humerus on 05/12/23, osteoarthritis, left hand contracture, depression, and Alzheimer's disease. Review of MDS dated [DATE] revealed that Resident #149 had a Brief Interview of Mental Status of not finished that indicated she was severely cognitively impaired. Resident required extensive two-person assist for bed mobility, transfers, toileting, personal hygiene, and bathing. Resident used a wheelchair and staff ambulated her. Resident was incontinent of bowel and bladder that was frequently incontinent. Review of plan of care dated 05/12/23 revealed that Resident #149 was at risk bladder and bowels incontinence. Interventions included check routinely for incontinence and provide incontinence care as needed, observe for signs of urinary tract infection, observe skin during care, and skin check weekly. Observation on 09/12/23 at 12:42 P.M. with Resident #149 revealed STNA #322 had placed Resident #149 who was in a wheelchair next to her bed on the right side to transfer her into bed to perform incontinence care. Resident #149's incontinence product was heavily saturated with urine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 6 of 20 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 365396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Fairfield LLC 5200 Camelot Drive Fairfield, OH 45014 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)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 09/12/23 at 12:55 P.M. with STNA #322 verified that Resident #149 was heavily saturated with urine, and the last time she changed her brief was not on her shift. STNA #322 stated she though Resident #149 got up at 500 A.M. to 6:00 A.M. Review of facility policy titled Incontinence dated 11/28/22 stated that for all residents who were incontinent of bowel and bladder will receive appropriate treatment to prevent infections and to restore continence to the extent possible. Review of facility policy titled Activity of Daily Living dated 11/29/22, revealed care and services will be provided for bathing, dressing, transferring, and toileting. This deficiency represents non-compliance investigated under Complaint Number OH00146202. Based on record review, observation, interview, and policy review, the facility failed to ensure residents were provided with necessary care to maintain good personal hygiene. This affected three (#97, #16 and #149) of three reviewed for care of dependent residents. This census was 158. Findings included: 1. Review of the medical record for Resident #97 revealed an admission date of 08/19/20. Diagnoses included dementia, major depressive disorder, type two diabetes mellitus, chronic kidney disease stage 3B, and atrial fibrillation. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #97 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. This resident was assessed to require two-person total dependence with transfers, one-person extensive assistance with dressing, bathing, and toileting, and supervision with eating. Observations on 09/11/23, 09/12/23, and 09/13/23 during the annual survey, Resident #97 had chin hairs about an inch long. Interview on 09/13/23 at 11:29 A.M. Resident #97 stated she didn't like the chin hairs and had never been asked by staff to shave them. Interview on 09/13/23 at 11:33 A.M. with State Tested Nurse's Aide (STNA) #336 verified Resident #97 had about an inch long hairs on her chin. STNA #336 reported she had not asked Resident #97 if she wanted her chin hairs shaved but would take care of it. Review of the facility policy titled, Activities of Daily Living (ADL's), dated 11/29/22 revealed a resident who was unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 7 of 20 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 365396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Fairfield LLC 5200 Camelot Drive Fairfield, OH 45014 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff interview, and policy review, the facility failed to provide adequate interventions and/or supervision to ensure a resident who was assessed as being at risk for elopements did not elope from the facility and failed to ensure the an exterior gate on the secured unit was functioning appropriately. This affected one (#14) out of three residents reviewed for elopements and had the potential to affect 30 (#104, #39, #36, #48, #101, #27, #143, #14, #308, #58, #116, #149, #141, #62, #24, #70, #114, #94, #99, #60, #63, #28, #137, #151, #154, #133, #118, #153, #91, and #83) residents residing on the secured unit who were at risk for elopement. Additionally, the facility failed to ensure fall interventions were in place and to ensure safe transfers. This affected three (#99, #16, and #149) of eight residents reviewed for accidents. The facility census was 158. Findings include: 1. Review of the medical record of Resident #14 revealed an admission date of 09/20/19. Diagnoses included Alzheimer's disease, essential hypertension, hypothyroidism, major depressive disorder, generalized anxiety disorder, dementia with agitation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. The resident was assessed as wandering one to three days during the assessment period. The resident required limited assistance of one staff for transfers and was independent with ambulation and locomotion. Review of the Wandering/Elopement Risk Scale dated 05/09/23, revealed the resident scored a 10, indicating she was at risk for elopement due to being ambulatory, having a history of wandering, and having a medical diagnosis of dementia/cognitive impairment. The resident was noted to reside on a secured unit for safety. Review of the care plan dated 02/16/23 revealed the resident exhibited behavioral symptoms of wandering and resided on a memory care unit. Interventions included to maintain a safe environment and provide resident with diversional activities. Review of physician orders revealed an order dated 05/06/23 for the resident to be placed on a secured unit to maintain safe boundaries and/or benefit from low functioning activities related to diagnosis of dementia. Review of a Social Services Note dated 06/01/23 at 4:12 P.M. revealed social services spoke with Resident #14 and the resident expressed she felt like she may have done something she should not have done but did not know what it was. Resident #14 stated she wanted food from a local restaurant and that was all she could remember. Resident #14 expressed she got nervous when things did not look familiar around her but was more relaxed now that she was back in her room. Review of a nursing progress note dated 06/01/23 at 2:50 P.M., revealed a skin assessment was completed and no injury was noted. A pain assessment was completed without any signs or symptoms of pain. The resident did not exhibit any signs or symptoms of distress. A wanderguard was placed to the resident's right wrist. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 8 of 20 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 365396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Fairfield LLC 5200 Camelot Drive Fairfield, OH 45014 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of an Nurse Practitioner encounter note dated 06/02/23 revealed the resident was seen per the staff's request. The resident eloped from the facility the day prior, having gotten out due to a door malfunction, and was found two hours later near a gas station. The resident had no memory of the incident. Review of the elopement investigation dated 06/01/23 at 3:10 P.M. revealed facility staff were alerted by the front desk that a police officer was in the lobby stating she had a resident in her patrol car. Upon arrival to the front lobby, the officer stated staff from a local restaurant called them stating they had a confused woman in the restaurant. The officer arrived at the local restaurant and the resident told the officer her name. The resident was returned to her room and a full assessment was completed with no negative findings. New interventions were for the door company to evaluate the door and a wanderguard was placed to the right wrist. Review of the local police department report dated 06/01/23 at 2:57 P.M. revealed the officer was dispatched to a local restaurant because the caller believed the woman had dementia due to her behavior. Upon arrival, the resident had difficulty remembering much of anything aside from her name and date of birth . The resident was also able to give the officer some names of family members. The resident was able to provide the name of her son. The resident was returned back to the facility. The officer spoke with Assistant Director of Nursing (ADON) #307, who stated she was going to open an investigation into the matter because the doors were all alarmed and nobody knew how the resident would have been able to leave undetected. The resident was released back to the care of the facility. Interview on 09/14/23 at 11:22 A.M., Licensed Practical Nurse (LPN) #353 stated, on 06/01/23, near the end of the lunch meal, she responded to an alarm sounding at the back door. LPN #353 stated the alarm sounded for approximately 30 seconds and she went to the door and found a resident (unable to recall who the resident was) standing by the door. LPN #353 stated she redirected the resident and turned the alarm off. When queried, LPN #353 stated she looked outside the door, in both directions, and did not see anything. LPN #353 stated residents are always messing around with the door key pad and the alarm usually goes off four or five times on every shift. LPN #353 stated she did not initiate a head count after the alarm sounded and stated she went on to pass medications on the unit. LPN #353 confirmed staff later determined Resident #14 had eloped from the facility. LPN #353 confirmed Resident #14 did not sustain any injuries. Observation and interview on 09/14/23 at 11:45 A.M. revealed a surveyor pressed and held on the back door on the memory care unit. The door immediately began to alarm and LPN #396 responded to the alarm within 20 seconds. After 30 seconds, the door released, opening to the outside of the building, with a metal fence directly in front of the exit. To the left, a locked courtyard was observed. To the right, a metal gate with a key pad, which opened when pushed lightly, without a code. LPN #396 was present at the time of the observation and verified the gate opened without a code nor force. LPN #396 stated the last person through the gate may not have closed it all the way. LPN #396 stated she was the nurse on duty the day Resident #14 left the facility. LPN #396 stated she did not perform any head count initially, because she did not know the alarm had gone off. LPN #396 stated when Resident #14 returned the the facility, she was visibly upset and said everyone was so mean. LPN #396 stated she conducted a head count on the unit when the resident returned to the facility and did not identify any additional missing residents. LPN #396 confirmed a wanderguard was applied to Resident #14 after the elopement in addition to residing on the secured unit. LPN #396 confirmed Resident #14 has no eloped since the incident on 06/01/23. Observation from 09/14/23 from 11:48 A.M. to 12:00 P.M. with LPN #396 revealed there was a camera (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 9 of 20 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 365396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Fairfield LLC 5200 Camelot Drive Fairfield, OH 45014 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)

F 0689 positioned on the building, above the gate. Level of Harm - Minimal harm or potential for actual harm Interview on 09/14/23 at 2:51 P.M., the Administrator stated the cameras only maintain recording for six weeks, so facility was unable to retrieve camera footage of Resident #14 leaving the facility on 06/01/23. Residents Affected - Some Interview on 09/14/23 at 3:08 P.M., with ADON #307 stated she was the primary person who conducted the investigation into Resident #14's elopement. ADON #307 stated she did not review the cameras as part of the investigation because she found the door was faulty and did not believe further investigation was warranted. ADON #307 stated, upon identifying the door was not working correctly, she stayed at the door until the contractor came to repair the door that same evening. Observation and interview on 09/14/23 at 4:17 P.M., Maintenance Director (MD) #412 stated, if the door alarms, the gate should be checked. Observation at the same time, surveyor pushed the gate without entering a code and it opened. MD #412 verified the gate opened without a code being entered. The facility confirmed there have been no further elopements; however, the gate that wasn't properly functioning had the potential to affect 30 (#104, #39, #36, #48, #101, #27, #143, #14, #308, #58, #116, #149, #141, #62, #24, #70, #114, #94, #99, #60, #63, #28, #137, #151, #154, #133, #118, #153, #91, and #83) residents residing on the secured unit who were at risk for elopement. 2. Review of medical record for Resident #99 revealed a admission date 07/14/23. Diagnoses included Alzheimer's disease, depression, and osteoporosis. Review of MDS dated [DATE] revealed that Resident #99 had a Brief Interview of Mental Status of that was not finished that indicated she was severely cognitively impaired. Resident #99 required extensive two-person assist for bed mobility, transfers, toilet use, personal hygiene, and bathing. Resident #99 required extensive one-person assist for dressing and eating. Review of plan of care dated 01/11/22 revealed Resident #99 resident was at risk for falls or fall related injury and had poor safety awareness due to Dementia. Interventions included encourage participate in activities, encourage, and assist in wearing appropriate nonskid footwear, follow facility fall protocol, keep call light in reach, keep pathways clear and well lit, and assist with toileting. Observation and interview on 09/12/23 at 11:03 A.M. with State Tested Nursing Assistant (STNA) #357 who stated that Resident #99 was a fall risk, and she did not have any socks or shoes on while propelling in her wheelchair with bare feet. 3. Review of medical record revealed that Resident #16 had an admission date 05/18/23. Diagnoses included chronic obstructive pulmonary disease, Alzheimer's Disease, and hypertension. Review of MDS dated [DATE] that revealed Resident #16 had a BIMS of four that indicated she was severely cognitively impaired. Resident #16 required extensive two-person physical assist for bed mobility, toilet use, and bathing. Resident #16 required extensive one-person physical assist for personal hygiene, eating, dressing, and transfers. Review of plan of care dated 03/04/23 revealed Resident #16 was at risk for activity of daily living related to self-care performance deficit. Interventions included ace wraps to bilateral lower extremities wrap from toes to knees on in AM and off at bedtime, assist with eyeglasses, and transfers a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 10 of 20 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 365396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Fairfield LLC 5200 Camelot Drive Fairfield, OH 45014 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some two assist. Resident #16 was also at risk for potential injuries and falls related to impaired mobility, peripheral vascular disease, shortness of breath, anxiety, dementia, and Alzheimer's disease. Resident #16 had history of falls. Interventions included two-person assist with transfers, monitor safety and preventative devices for application, observe and report unsafe conditions, and a versa frame to toilet. Observation on 09/12/23 at 10:54 A.M. with STNA #357 who came into dining room to get Resident #16 to take to hallway shower room down the hall to toilet resident. Resident #16 in a Broda chair dressed in one non-skid sock on left foot. Resident #16 right foot wrapped in white gauze due to wound, and a blue foot protector (foot moon boot) on right foot for protection. STNA #357 did not place a gate belt on Resident #16, just chicken winged her under her right arm to pivot her to toilet. STNA #357 repositioned Resident #16 again because she was leaning to the right, away from the wall. Resident #16 incontinent brief was moderate saturated with urine and had leaked through her pants. STNA #357 left Resident #16 on the toilet unsupervised at 10:54 A.M. to grab a clean pair of pants. STNA #357 came back to the shower room with new pair of pants at 10:55 A.M. Interview on 09/12/23 at 11:10 A.M. with STNA #357 who verified that she did transfer Resident #16 by herself, but thought she was a one-person transfer. STNA #357 also verified that it was an unsafe transfer with her having the blue protectant boot on right foot. STNA #357 stated she did leave Resident #16 on the toilet alone to go get clean pants. Interview on 09/14/23 at 2:10 P.M. with Assistant Director of Nursing (ADON) #307 who stated that she was unaware of Resident #16 had a transfer be STNA #357 in a shower room bathroom. ADON #307 stated that the transfer with the right foot blue foot protector was not a safe transfer. 4. Review of medical record for Resident #149 revealed an admission date 05/12/23. Diagnoses included displace comminuted fracture of shaft of left humerus on 05/12/23, osteoarthritis, left hand contracture, depression, and Alzheimer's disease. Review of MDS dated [DATE] revealed that Resident #149 had a Brief Interview of Mental Status of not finished that indicated she was severely cognitively impaired. Resident #149 required extensive two-person assist for bed mobility, transfers, toileting, personal hygiene, and bathing. Resident #149 used a wheelchair and staff ambulated her. Resident #149 was incontinent of bowel and bladder that was frequently incontinent. Review of plan of care dated 05/12/23 revealed that Resident #149 was at risk for falls. Resident #149 had history of falls, incontinence, unsteady gait, wheelchair mobility, and dementia with poor safety awareness. Resident interventions were assisted with transfers, keep call light in reach, and encourage and assist to wear appropriate non skid footwear. Observation on 09/12/23 at 12:42 P.M. with Resident #149 that STNA #322 had placed Resident #149 who was in a wheelchair next to her bed on the right side to transfer her into bed to perform incontinence care. Resident #149 had regular socks on. STNA #322 picked up Resident #149 under her right arm, and STNA #322 placed her right hand on Resident #149 pants to transfer her into bed. When STNA #322 picked up Resident #149 she pulled on her pants to perform the transfer. STNA #322 did not use a gate belt or had a gate belt to use. STNA #322 then laid Resident #149 down in bed, and pushed and pulled her by her clothes to position her in bed. Resident #149 was upset and trying to fight the aid off. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 11 of 20 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 365396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Fairfield LLC 5200 Camelot Drive Fairfield, OH 45014 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Interview on 09/12/23 at 12:55 P.M. with STNA #322 who verified that Resident #149 did not have non-skid socks on, no gate belt, and an unsafe transfer. Review of facility policy titled Fall Management dated 06/2023, revealed that the facility would care plan would be developed for residents and interventions to address each residents' fall risks factors. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 12 of 20 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 365396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Fairfield LLC 5200 Camelot Drive Fairfield, OH 45014 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to provide medication per physician ordered. This affected one (#149) out of three residents reviewed for medication administration. Facility census was 158. Findings Included: Review of medical record for Resident #142 revealed an admission date of 12/13/22. Diagnoses included open wound of abdominal wall left lower quadrant without penetration into peritoneal cavity (non-orthopedic surgery) 06/12/23, local infections of skin and subcutaneous tissue, pressure ulcer of right heel stage four, pressure ulcer of left ankle stage four, pressure ulcer of part of back stage four, pressure ulcer of left heel stage four, pressure ulcer of unspecified site stage three, pressure ulcer right hip unstageable, and carrier of suspected carrier of methicillin resistant staphylococcus aureus on 02/24/23. Review of Minimum Data Set (MDS) dated [DATE] revealed Resident #142 had a BIMS of 07/17/23 revealed resident BIMS was 15 that indicated he was cognitively intact. Resident #142 required extensive two-person physical assist of bed mobility, toilet use, and personal hygiene. Resident #142 required extensive one-person assist of dressing. Resident #142 was total dependence with two-person for transfers. Review of plan of care dated 12/14/22 revealed Resident #142 was at risk for exhibits behavior symptoms of rejection of wound dressing changes, and rejection of toilet hygiene. Interventions included administer medication, allow resident to vent feelings and needs, approach resident in a calm and friendly manor, assess resident's needs food thirst, toileting, and positioning, behaviors per behavior management, encourage family involvement, explain before giving care, give resident as many choices as possible about care and activities, resident becomes combative or resistive, listen to resident's needs and adjust plan, maintain a safe environment for resident, notify physician and psych services for increases behaviors, provide resident personal space, and familiarize resident with own belongings and surroundings. Review of physician order dated 09/05/23 revealed Resident #142 had an order for Ceftazidime injection solution reconstituted one gram to give by intramuscularly for wound infection for 21 days. Review of physician order dated 07/12/23 revealed that Resident #149 was on contact precaution for Carbapenem Resistant Acinetobacter (CRAB) infection. Review of medication administration record dated from 09/01/23 to current for Resident #149 medication for dates 09/06/23, 09/07/23, 09/08/23, 09/09/23, 09/10/23, 09/12/23, and 09/13/23 at 9:00 A.M. Medication was held on 09/05/23 both 9:00 A.M. and 9:00 P.M., and held on 09/11/23 at 9:00 A.M. and 9:00 P.M. Review of wound culture lab result dated 09/18/23 revealed that Resident #149 revealed his wound culture should rare growth of of CRAB. Interview on 09/18/23 at 11:25 A.M. with Quality Assurance Pharmacist #516 revealed there was only (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 13 of 20 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 365396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Fairfield LLC 5200 Camelot Drive Fairfield, OH 45014 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few two deliveries to the facility on [DATE] and 09/12/23. There was no packing slip or signed confirmation for date 09/04/23 for the first Ceftazidime one gram medication, due to the contract delivery service did not have the signed document. Interview on 09/18/23 at 11:48 A.M. with Regional Nurse Consultant (RNC) #303 revealed she did see that there was medication Ceftazidime one gram intramuscular delivered one delivery on 09/04/23 of eight vials. RNC #303 stated it does look on the Medication Administration Record for September 2023, showed that he was administered 10 doses, when pharmacy only delivered eight vials of antibiotics. RNC #303 stated the facility did not keep the medication in the emergency drug supply. RNC #303 stated that on 09/11/23, Licensed Practical Nurse (LPN) #405 did not give either morning or night dose, because the facility did not have the medication at the facility. Review of document from pharmacy quality assurance documented on Quality Assurance Pharmacists #516 dated 09/18/23 revealed that Resident #149 Ceftazidime one gram injection only delivered eight vials on 09/04/23 to the facility. Interview on 09/18/23 at 12:25 P.M. with Director of Nursing (DON) stated she was going to investigate the nurses who gave the antibiotic intramuscular to Resident #149. DON stated there's a problem when charting the administration of medication when the facility did not have the medication. Review of facility policy titled Medication Administration dated medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review of facility policy titled Documentation in Medical Records dated 11/29/22 revealed that each resident medical record shall contain an accurate representation of an actual experiences of the residents. Licensed staff and interdisciplinary team members should document all assessments, observations, and services provided to the resident. This deficiency represents non-compliance investigated under Complaint Number OH00146202. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 14 of 20 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 365396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Fairfield LLC 5200 Camelot Drive Fairfield, OH 45014 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)

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 food was stored in a manner to prevent the potential spread of foodborne illness, the facility failed to ensure kitchen equipment was maintained in a clean manner, the facility failed to ensure utensils placed on meal trays were not handled by the eating surface and the facility failed to ensure foods reached the appropriate cooking temperature prior to serving. This had the potential to affect 156 out of 156 residents in the facility who received food from the kitchen, the facility identified two residents (#06 and #108) who did not receive food from the kitchen. The facility census was 158. Findings include: 1. Observations on 09/11/23 at 9:20 A.M. during the initial tour of the kitchen revealed the following: a). In the walk-in freezer, there was a box of crab cakes, a box of vegetarian chicken nuggets, and a box of vegetarian breakfast burritos which were all left with the inside plastic bag cut open and left open to air. b). In the dry storage area, there was a large box of of rice observed with the plastic cut open, left open to air, and with the scoop stored in the rice. Account Manager (AM) #505 was present at the time of the observations and verified the foods should have been resealed or wrapped and the scoop not stored in the rice. Review of the facility policy titled, Food Storage: Cold Foods, dated 04/2018, revealed all foods should be stored wrapped or in covered containers, labeled, and dated. 2. Observation on 09/11/23 at approximately 9:30 A.M. revealed the hood, above the steamers, stove, grill and oven, measured approximately 20 feet long. Half of the hood, above the grill and stove, was clean, however the other half of the hood, above the oven and steamers was was coated in a dark fuzzy substance. Further observation revealed the hood had a sticker, indicating it had been cleaned on 08/24/23. Interview at the same time, AM #505 verified the hood was not fully clean. AM #505 stated a company had recently come out to clean the hood, however she was unsure why only half of it was cleaned. 3. Observation on 09/13/23 at 12:08 P.M. revealed dietary staff preparing meal trays for the lunch meal. Dietary Aid (DA) #513 was observed reaching into a plastic, 3-compartment tray for silverware. The silverware in the tray contained knives, forks, and spoons, which were pointed in different directions, including sideways. As she was preparing several meal trays, DA #513 was observed reaching for one of each piece of silverware, handling some by the eating surface as she grabbed them. Interview on 09/13/23 at 12:22 P.M., DA #513 verified the silverware in the tray was facing different ways and, as she was reaching in, she was touching the eating surfaces of the utensils. DA #513 stated, I think we all just grab in there without paying attention. Continuous observation on 09/13/23 from 12:22 P.M. through 12:30 P.M. revealed DA #513 continued to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 15 of 20 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 365396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Fairfield LLC 5200 Camelot Drive Fairfield, OH 45014 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many prepare meal trays and reach for the silverware, without regard to touching the eating surface. At times, DA #513 picked up more than one utensil at a time, felt the extra utensil and drop one, and, as a result, the utensils would continue to turn in different directions within the tray. Interview on 09/13/23 at approximately 2:00 P.M., AM #505 verified clean silverware should not be handled by the eating surface at any time. Review of the facility policy titled, Food: Preparation, dated 09/2017, revealed dining services staff was responsible for food preparation procedures that avoid contamination. 4. Observation on 09/13/23 at 11:47 A.M. revealed [NAME] #500 obtaining temperatures on all food items on the steam table prior to the start of meal service. [NAME] #500 temped the pureed chicken at 145 degrees Fahrenheit (F) and the regular chicken at 142 degrees F. [NAME] #500 stated she wanted the chicken to temp at 145 degrees F or higher and verified the pureed chicken temped at 145 degrees F and the regular chicken at 142 degrees F Continued observation revealed the pans of pureed and regular chicken remained on the steam table and were not reheated prior to starting tray line nor during tray line. Review of the weekly temperature record dated 09/11/23 through 09/17/23 revealed, on 09/13/23 at lunch, [NAME] #500 documented the temperature of the regular chicken at 145 degrees F and the pureed chicken at 142 degrees F. Interview on 09/13/23 at 1:03 P.M., AM #505 verified no temperatures were obtained when taking the food out of the oven because the [NAME] waited to do all of the temperatures with the surveyor. Follow-up interview on 09/13/23 at approximately 2:00 P.M., with AM #505 verified the regular and pureed chicken should have been reheated to an internal temperature of 165 degrees F prior to serving. The facility confirmed there were two (#06 and #108) current residents who did not receive their meals from the kitchen. Review of the facility policy titled, Food: Preparation, dated 09/2017, revealed Time/Temperature Control for Safety (TCS) hot food items will be cooked to a minimum internal temperature of 165 degrees F for 15 seconds for poultry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 16 of 20 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 365396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Fairfield LLC 5200 Camelot Drive Fairfield, OH 45014 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)

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 medical record review, observations, staff interviews, facility policy review and review of information from the Centers for Disease Control and Prevention (CDC), the facility failed to implement infection control practices to potentially prevent the spread of infectious diseases such as Coronavirus Disease 2019 (COVID-19) and/or Carbapenem-Resistant Acinetobacter Baumannii (CRAB). Additionally, the facility failed to develop and follow an infection disease program to aide in the potential spread of urinary tract infections (UTI) based on the facility identified concern from January 2023 through August 2023. This had the potential to affect all 158 residents who resided in the facility. The facility census was 158. Residents Affected - Many Findings include: 1. Record review for Resident #259 revealed she was admitted to the facility on [DATE]. Her diagnoses included supraventricular tachycardia, Myasthenia Gravis, and restless leg syndrome and COVID-19. Review of the New admission Minimum Data Set (MDS) assessment for Resident #259, dated 09/01/2, revealed she was cognitively intact. Further review of the MDS assessment revealed unable to determine from MDS assessment how much assistance was required (related to an unfinished assessment). However, review of the nursing progress notes revealed Resident #259 had limited ability to ambulate. Review of Resident #259's care plans including the Activity of Daily Living care plan revealed, Resident #259 required staff assistance with bathing, dressing, eating, and toilet use. Resident #259 had a care plan in place for COVID-19 diagnoses, dated 09/18/23 revealed, COVID diagnosis date initiated: 09/18/2023. Resident #259 will verbalize feelings related to emotional state, initiated: 09/18/202. Review of the physician orders for Resident #259 dated 09/11/23, Order Summary: Follow Contact and Droplet Isolation protocols, private room with all activities, meals, et treatments to be performed in room every shift for COVID. Observation on 09/11/23 at 12:32 P.M. revealed State Tested Nurse Aide (STNA) #306 opened the lunch tray cart and removed Resident #259's lunch tray. STNA #306 carried Resident #259's lunch tray to Resident #259's room and sat the lunch tray on the seat of a seated weight scale and opened the drawer of the three-drawer cart containing personal protective equipment (PPE). STNA #306 closed the drawer and picked up Resident #259's tray and returned it to the tray cart with other resident's lunches and walk down the hall and turn around and return to the lunch tray cart located in the resident's hallway. Observations revealed STNA #306 return to the lunch tray cart and took Resident #259's cart back out of the lunch tray cart and return it to the seat of the seated weight scale. STNA #306 opened the three-drawer cart containing PPE outside of Resident #259's room and don a pair of goggles over her N95 mask. STNA #306 turned and picked up Resident #259's lunch tray from the seated of the seated weight scale and entered Resident #259's room failing to don a gown, gloves, or foot cover. Observations revealed STNA # 396 exit #259's room wearing the same goggles and N95 mask as she walked into Resident #259 with and entered the hallway. Interview on 09/11/23 at 12:35 P.M. interview with STNA #306 verified after she exited Resident #259's room she went into the hallway. STNA #306 confirmed she failed to doff her goggles and continued (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 17 of 20 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 365396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Fairfield LLC 5200 Camelot Drive Fairfield, OH 45014 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm to wear the same soiled N95 mask into the resident's hallway. STNA #306 stated she did not don a gown and gloves because the isolation sign on the door states to wear goggles and N95 mask. STNA #306 stated the sign did not say to wear a gown and gloves. STNA #306 pointed to the sign advising staff to change their N95 mask and goggles. STNA #306 stated she has not had to deal with COVID-19 for several months and has forgotten everything about the proper precautions to take. Residents Affected - Many 2. Record review for Resident #26 revealed an admission date of 01/09/12. His diagnoses included retention of urine, osteoarthritis, paraplegia, multiple sclerosis, peripheral vascular disease, diabetes mellitus 2, and COVID-19. Review of Resident #26's quarterly MDS dated [DATE] revealed he was cognitively intact. Further review of the MDS assessment revealed he required extensive assistance from staff with bed mobility, dressing, toilet use, and personal hygiene. He was totally dependent on staff for transfers. Resident # 26 required limited assistance from staff with eating. Review of the physician orders revealed Resident #26, dated 09/08/23 stated, Follow Contact and Droplet Isolation Protocols, Private room with all activities, meals, example treatments to be performed in room every shift for COVID-19. Observation on 09/11/23 at 10:46 A.M. revealed Resident #26 had an isolation cart located outside his room along with signs stating he was in isolation. Upon entering Resident #26's room observations revealed a soiled PPE gown was crumbled on the chair next to Resident #26 along with a soiled mask and gloves. Resident #26's room did not have a doffing station to remove soiled PPE upon exiting the resident's room. Interview and observation with Unit Manager (UM) #366 confirmed the soiled gown, gloves, and mask were lying crumbled in the chair next to Resident #26's room. Observations revealed UM #366 walk out of Resident #26's isolation room and into the resident hallway. UM #366 confirmed she failed to doff her soiled N95 mask upon exiting the isolation room and entering into the hallway. Observed UM#366 remove her soiled mask while in the Resident hallway with no place to dispose of the soiled N95 and no mask on UM #366's face in the Resident hallway. Review of the facility policy titled, COVID-19 Resident Policy, updated January 2023, stated if a resident test positive for COVID-19 the Resident is placed in a private room or only residents with the same respiratory pathogen may be cohorted. The COVID-19 resident will be placed on droplet precautions. Care Team Members should follow basic infection control practices between residents including hand hygiene, respiratory etiquette, using dedicated equipment disinfecting shared equipment. Care Team Members should don a gown, face mask, eye protection, and gloves. Review of online resource per the CDC at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic updated 05/08/23 revealed healthcare workers who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH Approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). 3. Record review for Resident #47 revealed she was admitted to the facility on [DATE]. Her diagnoses included, cerebral infarction, end stage renal disease, diabetes mellitus 2, abdominal hernia, dependence on renal dialysis, contracture right hand, hyperlipidemia, essential primary hypertension, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 18 of 20 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 365396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Fairfield LLC 5200 Camelot Drive Fairfield, OH 45014 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)

F 0880 gastro-esophageal reflux disease, anemia, history of COVID-19, major depressive disorder, and edema. Level of Harm - Minimal harm or potential for actual harm Review of the quarterly MDS assessment, dated 08/02/23, revealed Resident #47 had a mild cognitive impairment. Resident #47 required extensive assistance from staff with bed mobility, dressing, toilet use and personal hygiene. Resident #47 was totally dependent on staff for transfers. She required supervision from staff with eating. Residents Affected - Many Review of Resident #47's physician orders revealed a revised physician's order dated, 08/14/23, Enhance Barrier Precautions. Review of the care plans for Resident #47's revealed, a care plan in place for Enhanced Barrier Precautions related to a laboratory test positive CRAB. Further review of the care plan stated Resident #47 required, enhanced barrier precaution. Observation and interview on 09/13/23 at 9:37 A.M. with Licensed Practical Nurse (LPN) #367 confirmed the facility did not have an isolation cart or supplies located outside of Resident #47's room. LPN #367 confirmed Resident #47 required enhanced precaution and stated the staff will walk into the room and DON the proper PPE while in the room and doff inside the room prior to exiting. Interview and observation on 09/12/23 at 10:05 A.M. observed Certified Occupational Therapist Assistant (COTA) #600 standing in front of Resident #47's wheelchair and COTA #600 had the right hand of Resident #47 in her hands. COTA #47 was wearing a surgical mask; however, she was not wearing the other required Personal Protective Equipment for enhanced barrier precautions. COTA #600 stated she totally forgot to wear the appropriate PPE prior to providing care to Resident #47. Review of information from the CDC at https://www.cdc.gov/hai/pdfs/cre/crab-handout-v7-508.pdf revealed CRAB is a bacteria that is an opportunistic pathogen. It can cause a variety of different types of infections. Infections caused by CRAB don ' t respond to common antibiotics and some CRAB infections are resistant to all available antibiotics. Protect your patients by wearing a gown and gloves for patient care according to the guidelines for your setting (i.e., Contact Precautions in acute care, Enhanced Barrier Precautions in long-term care). [NAME] and doff your personal protective equipment (PPE) in the right order and take care not to self-contaminate during doffing. Always change your PPE between patients or residents. 4. Review of the facility Infection Surveillance Program Revealed the following information regarding Resident's with UTI's at the facility during January 2023 through August 2023. The facility reported 22 UTI's in August 2023, 29 UTI's identified in July 2023, 17 UTI's in June 2023, 11 UTI's in May 2023, March the facility identified five UTI's. Further review of the facility surveillance of UTI's revealed in February 2023 the facility identified 14 UTI's along with the note,UTI's are still an issue this month. Peri Care and Hand hygiene will be the primary focus. In January 2023 the facility identified 24 UTI's total and a note that stated 8 UTI's the facility recognized a failure to provide proper hand hygiene and peri care. The Facility Infection Control Surveillance and Tracking confirmed the facility failed to address an ongoing issue with UTI's and reassess the issue for a different outcome. Interview on 09/18/23 at 3:11 P.M. with Regional Nurse Consultant (RNC) #303 stated the facility recognized an issue with peri care and had hygiene with the increased UTI's. RNC #303 confirmed the facility was unable to provide an effective on-going facility identified program that created a lower (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 19 of 20 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 365396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Fairfield LLC 5200 Camelot Drive Fairfield, OH 45014 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)

F 0880 number of uti's in the facility. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Surveillance for Healthcare-Associated Infections, dated 02/2018 revealed the facility Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIS). The purpose of the surveillance of infections is to identify both individual cases and trends in the transmission of epidemiologically significant organism and Healthcare Associated Infections, to permit interventions and try to slow or stop the transmission of infections. Residents Affected - Many This deficiency represents non-compliance investigated under Complaint Number OH00146202. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 20 of 20