Inspection·October 31, 2023

F 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to provide a resident with appropriate behavioral health treatment and services. This affected one (#152) out of the three residents reviewed for behaviors. The facility census was 159. Findings included: Review of the medical record for Resident #152 revealed an admission date of 03/29/23 with medical diagnoses of Alzheimer's disease, chronic obstructive pulmonary disease, and anxiety. Further review revealed Resident #152 went on leave of absence (LOA) with his daughter on 10/20/23 and was discharged from the facility on 10/26/23. Review of the medical record for Resident #152 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #152 had moderate cognitive impairment and required supervision with bed mobility, transfers, toileting, eating, and bathing. The MDS did not indicate Resident #152 had any behaviors. Review of the medical record for Resident #152 revealed a psychiatry progress note, dated 10/13/23, which stated psychosis or behaviors observed. The stated Resident #152 made delusional comments related to someone stealing his wife's items when she resided at the facility. The psychiatry notes did not contain documentation regarding sexually inappropriate behaviors with staff or other residents. Review of the medical record for Resident #152 revealed a nurse progress note, dated 10/16/23 at 3:59 P.M., which stated the facility attempted to contact Resident #152's emergency contacts to notify them Resident #152 was assisting other residents into bed despite attempts to encourage resident not to assist. The note stated Resident #512 was on line of sight supervision. Review of a nurse progress note, dated 10/16/23 at 7:11 P.M. stated Resident #152 was walking around the facility, supervised by staff, and kept within staff eyesight. The note stated Resident #152 would attempt to propel several residents in their wheelchair and staff discouraged with minimal assistance. Review of a nurse progress note, dated 10/17/23 at 6:29 P.M., stated Resident #152 walked around the facility and wanted to help other residents by pushing them in their wheelchairs. The note stated Resident #152 was very friendly and did not attempt to go into other resident's rooms. Review of the medical record for Resident #152 revealed a Certified Nurse Practitioner (CNP) note, dated 10/17/23, which stated to start medroxyprogesterone acetate suspension intramuscular (contraceptive). The note stated staff reported Resident #152 has been spending a lot of time with female (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 365396 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 10/31/2023 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)