Inspection·December 21, 2023

F 0694 Level of Harm - Minimal harm or potential for actual harm Review of Medication Administration Records (MARs) revealed Resident #03 received the physician ordered nutrition IV infusions on 05/08/23, 06/09/23, 07/07/23, 08/02/23, and 09/06/23. Interview with Resident #03 on 12/04/23 at 11:10 A.M. revealed no concerns related to the IV services received from DRIPT IV. Residents Affected - Some 2) Review of the medical record for Resident #26 revealed the resident was admitted on [DATE]. Diagnoses included hypertension, gastroesophageal reflux disease (GERD), diabetes hyperlipidemia, anxiety, depression, and asthma, Review of the MDS assessment dated [DATE] for Resident #26, revealed the resident had intact cognition. Review of the care plan for Resident #26 revealed areas of focus for risk for nutrition and skin integrity. Review of the physician's orders dated 07/02/23. 08/02/23 and 09/06/23 for Resident #26 , revealed the resident was ordered to receive Derma infusion protocol for DRIPT IV nurse via IV one-time monthly 500 mLs of 0.9 % NS at rate of 250 mLs an hr. (total additive volume of 30.4 mLs) Additive formula: Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 100 mgs, vitamin C (ascorbic acid) 5 gms, Vitamin B5 (Dexpanthenol) 250 mgs, Vitamin B6 (Pyridoxine) 4 mgs, Vitamin B12 (Methylcobalamin) 2 mgs, Vitamin B7 (Biotin) 20 mg, Magnesium Chloride 900 mgs, Calcium Chloride 200 mgs, Gluconate 200 mg, Zinc 10 mgs and Amino blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mg Taurine 100 mgs, and Glycine 100 mg) every month for micronutrient hydration therapy. Review of the MARs for Resident #26 revealed the resident received the physician ordered infusions on 07/07/23, 08/02/23, and 09/06/23. 3) Review of medical record for Resident #36 revealed the resident was admitted on [DATE]. Diagnoses included non-traumatic brain dysfunction, anemia hypertension, peripheral vascular disease (PVD), GERD, diabetes, hyperlipidemia, Alzheimer's disease, dementia, and asthma. Review of the MDS assessment dated [DATE] for Resident #36 revealed the resident had intact cognition. Review of the Care Plan for Resident #36 revealed areas of focus for risk for nutrition and skin impairment. Review of the physician's ordered dated 06/09/23 and 09/06/23 for Resident #36 revealed the resident was ordered to receive Derma infusion protocol for DRIPT IV nurse via IV one-time monthly 500 mLs of 0.9 % NS at rate of 250 mLs an hr. (total additive volume of 30.4 mLs) Additive formula: Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 100 mgs, vitamin C (ascorbic acid) 5 gms, Vitamin B5 (Dexpanthenol) 250 mgs, Vitamin B6 (Pyridoxine) 4 mgs, Vitamin B12 (Methylcobalamin) 2 mgs, Vitamin B7 (Biotin) 20 mg, Magnesium Chloride 900 mgs, Calcium Chloride 200 mgs, Gluconate 200 mg, Zinc 10 mgs and Amino blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mg Taurine 100 mgs, and Glycine 100 mg) every month for micronutrient hydration therapy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 2 of 15 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 12/21/2023 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 0694 Level of Harm - Minimal harm or potential for actual harm Review of the MARs for Resident #36, revealed the resident received the physician ordered infusions on 06/09/23 and 09/06/23. Interview with Resident #36 on 12/04/23 at 11:22 A.M. revealed no concerns related to the IV services received from DRIPT-IV. Residents Affected - Some 4) Review of medical records for Resident #23 revealed an admission date of 07/18/15. Diagnoses included coronary artery disease, hear failure, hypertension, Peripheral vascular disease, anxiety, asthma, hyperlipidemia, and Alzheimer's disease, Review of the MDS assessment dated [DATE] for Resident #23, revealed the resident had severely impaired cognition. Review of the physician's ordered dated 07/07/23, 08/02/23 and 09/06/23 for Resident #23 revealed the resident was ordered to receive Derma infusion protocol for DRIPT IV nurse via IV one-time monthly 500 mLs of 0.9 % NS at rate of 250 mLs an hr. (total additive volume of 30.4 mLs) Additive formula: Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 100 mgs, vitamin C (ascorbic acid) 5 gms, Vitamin B5 (Dexpanthenol) 250 mgs, Vitamin B6 (Pyridoxine) 4 mgs, Vitamin B12 (Methylcobalamin) 2 mgs, Vitamin B7 (Biotin) 20 mg, Magnesium Chloride 900 mgs, Calcium Chloride 200 mgs, Gluconate 200 mg, Zinc 10 mgs and Amino blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mg Taurine 100 mgs, and Glycine 100 mg) every month for micronutrient hydration therapy. Review of MARs revealed Resident #23 received the physician ordered infusions on 07/07/23, 08/02/23, and 09/06/23. Interview with the Administrator and the Director of Nursing (DON) on 12/04/23 revealed they were unaware that the ancillary provider (DRIPT IV) did not possess a Terminal Distributor of Dangerous Drugs (TDDD) license for the State of Ohio when they provided IV services to the facility. The DON verified that the above listed residents received IV infusions provided by the ancillary provider. Interview with Regional Clinical Director (RCD) #600 on 12/05/23 at 2:15 P.M. revealed on 11/14/23 the Administrator from their sister facility ([NAME] of Middletown) notified them that DRIPT IV was no longer servicing the Ohio market and there was no additional information provided as to the reasoning. RCD #600 reported that all of the residents were assessed and any changes in conditions were discussed on a daily basis and there were no issues noted. Registered Nurse #110 with the interdisciplinary team (IDT) was assigned to do the resident record reviews. RCD #600 reported their Corporate Chief Executive Officer (CEO) # 115 educated the Administrators, Regional Nurses, and Regional Administrators of the requirement to verify the TDDD for all vendors. RCD #600 reported medication education occurred on 11/09/23 that was related to a similar situation to the findings of another complaint survey, and the training was appropriate for both the previous complaint and the current investigation. RCD #600 stated that the clinical documentation for all residents who received DRIPT therapy was reviewed for any negative outcomes or undesirable results. Attempts to interview Medical Director (MD) #100 on 12/07/23 and 12/12/23 were unsuccessful. Interview with Representative #405 for the ancillary provider stated they did not have State of Ohio TDDD licensure. He stated they were a Medical Entity, with a Medical Director licensed in the State of Ohio. Every other state in which they provided services did not require a special TDDD license (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 3 of 15 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 12/21/2023 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and after about three months of providing services in the Ohio area, they learned Ohio was an exception. He stated they applied for the license and were told they could continue providing services, license approval would take days. He stated an audit was conducted, and the Board of Pharmacy reported them. Simultaneously, the group had decided to stop providing services in Ohio unrelated to the licensure concerns. They rescinded their application for licensure. He stated they provided five specialized infusions that could be specialized based on resident needs. The intervention was created a couple of years ago and found to be beneficial for residents with chronic urinary tract infections (UTI), residents who did not eat or drink well, and/or weight loss concerns. He stated they presented the program to facility ownership. Interview with the facilities General Counsel #406 stated studies had shown hydration therapy improved and reduced risk of dehydration and rehospitalization. General Counsel #406 stated she learned of this licensing concern on 11/14/23 and had contacted the General Counsel for the ancillary provider who reported when they started the process in Ohio, they had been told they did not require TDDD license for Ohio. They reported they were initially told by the Board of Pharmacy they did not require an Ohio license, there were a ton of exemptions. They reported they applied for the license. General Counsel #406 stated the provider did not explain concerns with licensure when they announced they were no longer providing services. It was explained as a decrease in services related to rate freezes. General Counsel #406 stated she was not involved with the initial vetting process and could not provide specific information as to the steps involved in the approval. The corporation had started a compliance investigation on this with a compliance officer specific to this incident. General Counsel #406 revealed the contract had been signed on 12/09/22 by their Chief Financial Officer (CFO). The General Counsel at that time would have gone through a legal review with a multi-layered vetting process before it was presented to the CFO. She was in the process of investigating everything involved in the process and was still gathering information. Review of the State of Ohio Terminal Distributor Licensure of Prescriber Practices (https://www.pharmacy.ohio.gov), dated 08/24/23, revealed a TDDD license allows a business entity to purchase, possess, and/or distribute dangerous drugs at specific locations. Terminal distributors of dangerous drugs include, but are not limited to, hospitals, pharmacies, Emergency Medical Services (EMS) organizations, laboratories, nursing homes, and prescriber practices. Distribution includes the administration of drugs on-site to patients as well as providing medications to patients to take away from the facility for later use. Dangerous drugs are defined in the Ohio Revised Code as any drug that meets any of the following: 1. Requires a subscription; 2. Bears on the label a Federal Legend (Rx Only or Caution: Federal law prohibits dispensing without a prescription); 3. Is intended for injection into the human body; or 4. Any drug that is a biological product as defined in section 3715.01 of the Revised Code. Ohio Revised Code (ORC) 4729.51 states that no licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor shall sell dangerous drugs to anyone other than the following: (1) a licensed terminal distributor of dangerous drugs; (2) Any person exempt from licensure as a terminal distributor of dangerous drugs under section 4729.541 of the Revised Code (3) a licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor; or (4) A terminal distributor, manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor that is located in another state, is not engaged in the sale of dangerous drugs within this state, and is actively licensed to engage in the sale of dangerous drugs by the state in which the distributor conducts business. In general, the exemptions to Ohio's TDDD licensure requirements do not apply if the prescriber practice is engaged in drug compounding. Compounding is defined as the preparation, mixing, assembling, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 4 of 15 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 12/21/2023 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 0694 packaging, and labeling of one or more drugs. Compounding includes the combining, admixing, diluting, reconstituting, or otherwise altering of a drug or bulk drug substance. Level of Harm - Minimal harm or potential for actual harm The deficiency was corrected on 11/19/23 after the facility implemented the following corrective actions: Residents Affected - Some On 09/06/23 was the last utilization of services from DRIPT IV. On 09/22/23, the contract with DRIPT IV cessation was effective. On 11/14/23, the facility was notified that DRIPT IV solution vendor company who serviced the facility did not have a TDD licensure required in Ohio to dispense drugs. The Corporate attorney and Corporate Director of Procurement were notified by the RCD #600 On 11/15/23, all current residents who received DRIPT IV services were audited by RN #110 for change of condition related to receiving IVs from DRIPT IV and no issues were found. On 11/15/23, the governing body policy was revised and adopted by the Quality Assurance Performance Improvement (QAPI) committee during their meeting. On 11/15/23, the QAPI Committee was educated on the governing body policy by Corporate. On 11/15/23, the QAPI Committee will review any new contracts via the QAPI committee to ensure licensure is validated and compliant with the governing policy. The QAPI committee will meet monthly as needed. On 11/15/23, the Administrator and/or the DON will be responsible for monitoring on going compliance. On 11/19/23, all licensed nurses were educated on the medication administration and medication documentation by RN #100 Review of four Residents (#01, #09, #11, and #12) medical records revealed assessments were completed. This deficiency represents non-compliance investigated under Complaint Number OH00148166. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 5 of 15 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 12/21/2023 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 - Some 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** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, and interview the facility failed to ensure medications were obtained from a source with a Terminal Distributor of Dangerous Drugs (TDDD) license (which allows a business entity to purchase, possess, and/or distribute dangerous drugs at a specific location) specific to the State of Ohio. This affected four (#03, #26, #23 and #36) of the four residents reviewed for medications administered by a contracted ancillary provider. This also affected 40 additional current Residents (#01, #02, #09, #10, #11, #12, #13, #16,, #17, #18, #19, #20, #22, #28, #31, #32, #33, #34, #35, #37, #39, #40, #41, #42, #43, #44, #45, #46, #48, #49, #51, #52, #53, #55, #56, #57, #58, #60, #61, and #62) and 15 discharged Residents (#04, #05, #06, #08, #14, #15, #21, #25, #27, #29, #30, #47, #50, #54, and #59) for total of 59 residents. The facility census was 153. Findings include: 1) Review of the medical record for Resident #03 revealed the resident was admitted on [DATE], Diagnosis included anemia, coronary artery disease hypertension, hyperlipidemia, hip fracture, dementia, Parkinson's disease, anxiety, and depression. Review of the Minimum Data Set (MDS) assessment 3.0 dated 10/13/23 for Resident #03, revealed the resident had intact cognition. Review of the Care Plan for Resident #03 revealed areas of resident focus for risks related to hydration, nutrition, and skin integrity. Review of the physician's orders dated 05/08/23, 06/09/23, 07/07/23, 08/02/23 and 09/06/23 for Resident #03, revealed the resident was ordered to receive cognition infusion protocol - DRIPT IV (entity who provides hydration and vitamin nutrient therapy) intravenously (IV) one-time monthly 500 milliliters (mLs) of 0.9 percent (%) normal saline (NS) at rate of 250 mLs an hour (hr.) (total additive volume of 30.4 mLs) Additive formula: Vitamin B1 complex (Thiamine [Thia]) 200 milligrams (mgs), Vitamin B2 (Riboflavin [Ribo]) 4 mgs, Vitamin B3 (Niacin [Nia]) 100 mgs, vitamin C (ascorbic acid) 5 grams (gms), Vitamin B5 (Dexpanthenol) 250 mgs, Vitamin B6 (Pyridoxine [Pyr]) 4 mgs, Vitamin B12 (Methylcobalamin) 2 mgs, Vitamin B7 (Biotin) 20 mg, Magnesium Chloride 900 mgs, Calcium Chloride 200 mgs, Gluconate 200 mg, Zinc 10 mgs and Amino blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mg Taurine 100 mgs, and Glycine 100 mg) one daily for cognition via IV for cognition and infusion of micronutrient hydration therapy. Review of Medication Administration Records (MARs) revealed Resident #03 received the physician ordered nutrition IV infusions on 05/08/23, 06/09/23, 07/07/23, 08/02/23, and 09/06/23. Interview with Resident #03 on 12/04/23 at 11:10 A.M. revealed no concerns related to the IV services received from DRIPT IV. 2) Review of the medical record for Resident #26 revealed the resident was admitted on [DATE]. Diagnoses included hypertension, gastroesophageal reflux disease (GERD), diabetes hyperlipidemia, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 6 of 15 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 12/21/2023 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 anxiety, depression, and asthma, Level of Harm - Minimal harm or potential for actual harm Review of the MDS assessment dated [DATE] for Resident #26, revealed the resident had intact cognition. Review of the care plan for Resident #26 revealed areas of focus for risk for nutrition and skin integrity. Residents Affected - Some Review of the physician's orders dated 07/02/23. 08/02/23 and 09/06/23 for Resident #26 , revealed the resident was ordered to receive Derma infusion protocol for DRIPT IV nurse via IV one-time monthly 500 mLs of 0.9 % NS at rate of 250 mLs an hr. (total additive volume of 30.4 mLs) Additive formula: Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 100 mgs, vitamin C (ascorbic acid) 5 gms, Vitamin B5 (Dexpanthenol) 250 mgs, Vitamin B6 (Pyridoxine) 4 mgs, Vitamin B12 (Methylcobalamin) 2 mgs, Vitamin B7 (Biotin) 20 mg, Magnesium Chloride 900 mgs, Calcium Chloride 200 mgs, Gluconate 200 mg, Zinc 10 mgs and Amino blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mg Taurine 100 mgs, and Glycine 100 mg) every month for micronutrient hydration therapy. Review of the MARs for Resident #26 revealed the resident received the physician ordered infusions on 07/07/23, 08/02/23, and 09/06/23. 3) Review of medical record for Resident #36 revealed the resident was admitted on [DATE]. Diagnoses included non-traumatic brain dysfunction, anemia hypertension, peripheral vascular disease (PVD), GERD, diabetes, hyperlipidemia, Alzheimer's disease, dementia, and asthma. Review of the MDS assessment dated [DATE] for Resident #36 revealed the resident had intact cognition. Review of the Care Plan for Resident #36 revealed areas of focus for risk for nutrition and skin impairment. Review of the physician's ordered dated 06/09/23 and 09/06/23 for Resident #36 revealed the resident was ordered to receive Derma infusion protocol for DRIPT IV nurse via IV one-time monthly 500 mLs of 0.9 % NS at rate of 250 mLs an hr. (total additive volume of 30.4 mLs) Additive formula: Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 100 mgs, vitamin C (ascorbic acid) 5 gms, Vitamin B5 (Dexpanthenol) 250 mgs, Vitamin B6 (Pyridoxine) 4 mgs, Vitamin B12 (Methylcobalamin) 2 mgs, Vitamin B7 (Biotin) 20 mg, Magnesium Chloride 900 mgs, Calcium Chloride 200 mgs, Gluconate 200 mg, Zinc 10 mgs and Amino blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mg Taurine 100 mgs, and Glycine 100 mg) every month for micronutrient hydration therapy. Review of the MARs for Resident #36, revealed the resident received the physician ordered infusions on 06/09/23 and 09/06/23. Interview with Resident #36 on 12/04/23 at 11:22 A.M. revealed no concerns related to the IV services received from DRIPT-IV. 4) Review of medical records for Resident #23 revealed an admission date of 07/18/15. Diagnoses included coronary artery disease, hear failure, hypertension, Peripheral vascular disease, anxiety, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 7 of 15 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 12/21/2023 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 asthma, hyperlipidemia, and Alzheimer's disease, Level of Harm - Minimal harm or potential for actual harm Review of the MDS assessment dated [DATE] for Resident #23, revealed the resident had severely impaired cognition. Residents Affected - Some Review of the physician's ordered dated 07/07/23, 08/02/23 and 09/06/23 for Resident #23 revealed the resident was ordered to receive Derma infusion protocol for DRIPT IV nurse via IV one-time monthly 500 mLs of 0.9 % NS at rate of 250 mLs an hr. (total additive volume of 30.4 mLs) Additive formula: Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 100 mgs, vitamin C (ascorbic acid) 5 gms, Vitamin B5 (Dexpanthenol) 250 mgs, Vitamin B6 (Pyridoxine) 4 mgs, Vitamin B12 (Methylcobalamin) 2 mgs, Vitamin B7 (Biotin) 20 mg, Magnesium Chloride 900 mgs, Calcium Chloride 200 mgs, Gluconate 200 mg, Zinc 10 mgs and Amino blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mg Taurine 100 mgs, and Glycine 100 mg) every month for micronutrient hydration therapy. Review of MARs revealed Resident #23 received the physician ordered infusions on 07/07/23, 08/02/23, and 09/06/23. Interview with the Administrator and the Director of Nursing (DON) on 12/04/23 revealed they were unaware that the ancillary provider (DRIPT IV) did not possess a Terminal Distributor of Dangerous Drugs (TDDD) license for the State of Ohio when they provided IV services to the facility. The DON verified that the above listed residents received IV infusions provided by the ancillary provider. Interview with Regional Clinical Director (RCD) #600 on 12/05/23 at 2:15 P.M. revealed on 11/14/23 the Administrator from their sister facility ([NAME] of Middletown) notified them that DRIPT IV was no longer servicing the Ohio market and there was no additional information provided as to the reasoning. RCD #600 reported that all of the residents were assessed and any changes in conditions were discussed on a daily basis and there were no issues noted. Registered Nurse #110 with the interdisciplinary team (IDT) was assigned to do the resident record reviews. RCD #600 reported their Corporate Chief Executive Officer (CEO) # 115 educated the Administrators, Regional Nurses, and Regional Administrators of the requirement to verify the TDDD for all vendors. RCD #600 reported medication education occurred on 11/09/23 that was related to a similar situation to the findings of another complaint survey, and the training was appropriate for both the previous complaint and the current investigation. RCD #600 stated that the clinical documentation for all residents who received DRIPT therapy was reviewed for any negative outcomes or undesirable results. Attempts to interview Medical Director (MD) #100 on 12/07/23 and 12/12/23 were unsuccessful. Interview with Representative #405 for the ancillary provider stated they did not have State of Ohio TDDD licensure. He stated they were a Medical Entity, with a Medical Director licensed in the State of Ohio. Every other state in which they provided services did not require a special TDDD license and after about three months of providing services in the Ohio area, they learned Ohio was an exception. He stated they applied for the license and were told they could continue providing services, license approval would take days. He stated an audit was conducted, and the Board of Pharmacy reported them. Simultaneously, the group had decided to stop providing services in Ohio unrelated to the licensure concerns. They rescinded their application for licensure. He stated they provided five specialized infusions that could be specialized based on resident needs. The intervention was created a couple of years ago and found to be beneficial for residents with chronic urinary tract infections (UTI), residents who did not eat or drink well, and/or weight loss concerns. He stated they presented (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 8 of 15 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 12/21/2023 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 the program to facility ownership. Level of Harm - Minimal harm or potential for actual harm Interview with the facilities General Counsel #406 stated studies had shown hydration therapy improved and reduced risk of dehydration and rehospitalization. General Counsel #406 stated she learned of this licensing concern on 11/14/23 and had contacted the General Counsel for the ancillary provider who reported when they started the process in Ohio, they had been told they did not require TDDD license for Ohio. They reported they were initially told by the Board of Pharmacy they did not require an Ohio license, there were a ton of exemptions. They reported they applied for the license. General Counsel #406 stated the provider did not explain concerns with licensure when they announced they were no longer providing services. It was explained as a decrease in services related to rate freezes. General Counsel #406 stated she was not involved with the initial vetting process and could not provide specific information as to the steps involved in the approval. The corporation had started a compliance investigation on this with a compliance officer specific to this incident. General Counsel #406 revealed the contract had been signed on 12/09/22 by their Chief Financial Officer (CFO). The General Counsel at that time would have gone through a legal review with a multi-layered vetting process before it was presented to the CFO. She was in the process of investigating everything involved in the process and was still gathering information. Residents Affected - Some Review of the State of Ohio Terminal Distributor Licensure of Prescriber Practices (https://www.pharmacy.ohio.gov), dated 08/24/23, revealed a TDDD license allows a business entity to purchase, possess, and/or distribute dangerous drugs at specific locations. Terminal distributors of dangerous drugs include, but are not limited to, hospitals, pharmacies, Emergency Medical Services (EMS) organizations, laboratories, nursing homes, and prescriber practices. Distribution includes the administration of drugs on-site to patients as well as providing medications to patients to take away from the facility for later use. Dangerous drugs are defined in the Ohio Revised Code as any drug that meets any of the following: 1. Requires a subscription; 2. Bears on the label a Federal Legend (Rx Only or Caution: Federal law prohibits dispensing without a prescription); 3. Is intended for injection into the human body; or 4. Any drug that is a biological product as defined in section 3715.01 of the Revised Code. Ohio Revised Code (ORC) 4729.51 states that no licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor shall sell dangerous drugs to anyone other than the following: (1) a licensed terminal distributor of dangerous drugs; (2) Any person exempt from licensure as a terminal distributor of dangerous drugs under section 4729.541 of the Revised Code (3) a licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor; or (4) A terminal distributor, manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor that is located in another state, is not engaged in the sale of dangerous drugs within this state, and is actively licensed to engage in the sale of dangerous drugs by the state in which the distributor conducts business. In general, the exemptions to Ohio's TDDD licensure requirements do not apply if the prescriber practice is engaged in drug compounding. Compounding is defined as the preparation, mixing, assembling, packaging, and labeling of one or more drugs. Compounding includes the combining, admixing, diluting, reconstituting, or otherwise altering of a drug or bulk drug substance. The deficiency was corrected on 11/19/23 after the facility implemented the following corrective actions: On 09/06/23 was the last utilization of services from DRIPT IV. On 09/22/23, the contract with DRIPT IV cessation was effective. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 9 of 15 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 12/21/2023 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 - Some On 11/14/23, the facility was notified that DRIPT IV solution vendor company who serviced the facility did not have a TDD licensure required in Ohio to dispense drugs. The Corporate attorney and Corporate Director of Procurement were notified by the RCD #600 On 11/15/23, all current residents who received DRIPT IV services were audited by RN #110 for change of condition related to receiving IVs from DRIPT IV and no issues were found. On 11/15/23, the governing body policy was revised and adopted by the Quality Assurance Performance Improvement (QAPI) committee during their meeting. On 11/15/23, the QAPI Committee was educated on the governing body policy by Corporate. On 11/15/23, the QAPI Committee will review any new contracts via the QAPI committee to ensure licensure is validated and compliant with the governing policy. The QAPI committee will meet monthly as needed. On 11/15/23, the Administrator and/or the DON will be responsible for monitoring on going compliance. On 11/19/23, all licensed nurses were educated on the medication administration and medication documentation by RN #100 Review of four Residents (#01, #09, #11, and #12) medical records revealed assessments were completed. This deficiency represents non-compliance investigated under Complaint Number OH00148166. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 10 of 15 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 12/21/2023 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 0837 Level of Harm - Minimal harm or potential for actual harm Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 837 Residents Affected - Some THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, review of facility policy, and interview the facility failed to ensure a contracted entity had appropriate State of Ohio required credentials for provision of services for residents. This deficiency affected four of four Residents (#27, #89, #85, and #30) reviewed for medications administered by a contracted ancillary provider. This affected four (#03, #26, #23 and #36) of the four residents reviewed for medications administered by a contracted ancillary provider. This also affected 40 additional current Residents (#01, #02, #09, #10, #11, #12, #13, #16,, #17, #18, #19, #20, #22, #28, #31, #32, #33, #34, #35, #37, #39, #40, #41, #42, #43, #44, #45, #46, #48, #49, #51, #52, #53, #55, #56, #57, #58, #60, #61, and #62) and 15 discharged Residents (#04, #05, #06, #08, #14, #15, #21, #25, #27, #29, #30, #47, #50, #54, and #59) for total of 59 residents. The facility census was 153. Findings include: 1) Review of the medical record for Resident #03 revealed the resident was admitted on [DATE], Diagnosis included anemia, coronary artery disease hypertension, hyperlipidemia, hip fracture, dementia, Parkinson's disease, anxiety, and depression. Review of the Minimum Data Set (MDS) assessment 3.0 dated 10/13/23 for Resident #03, revealed the resident had intact cognition. Review of the Care Plan for Resident #03 revealed areas of resident focus for risks related to hydration, nutrition, and skin integrity. Review of the physician's orders dated 05/08/23, 06/09/23, 07/07/23, 08/02/23 and 09/06/23 for Resident #03, revealed the resident was ordered to receive cognition infusion protocol - DRIPT IV (entity who provides hydration and vitamin nutrient therapy) intravenously (IV) one-time monthly 500 milliliters (mLs) of 0.9 percent (%) normal saline (NS) at rate of 250 mLs an hour (hr.) (total additive volume of 30.4 mLs) Additive formula: Vitamin B1 complex (Thiamine [Thia]) 200 milligrams (mgs), Vitamin B2 (Riboflavin [Ribo]) 4 mgs, Vitamin B3 (Niacin [Nia]) 100 mgs, vitamin C (ascorbic acid) 5 grams (gms), Vitamin B5 (Dexpanthenol) 250 mgs, Vitamin B6 (Pyridoxine [Pyr]) 4 mgs, Vitamin B12 (Methylcobalamin) 2 mgs, Vitamin B7 (Biotin) 20 mg, Magnesium Chloride 900 mgs, Calcium Chloride 200 mgs, Gluconate 200 mg, Zinc 10 mgs and Amino blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mg Taurine 100 mgs, and Glycine 100 mg) one daily for cognition via IV for cognition and infusion of micronutrient hydration therapy. Review of Medication Administration Records (MARs) revealed Resident #03 received the physician ordered nutrition IV infusions on 05/08/23, 06/09/23, 07/07/23, 08/02/23, and 09/06/23. Interview with Resident #03 on 12/04/23 at 11:10 A.M. revealed no concerns related to the IV (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 11 of 15 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 12/21/2023 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 0837 services received from DRIPT IV. Level of Harm - Minimal harm or potential for actual harm 2) Review of the medical record for Resident #26 revealed the resident was admitted on [DATE]. Diagnoses included hypertension, gastroesophageal reflux disease (GERD), diabetes hyperlipidemia, anxiety, depression, and asthma, Residents Affected - Some Review of the MDS assessment dated [DATE] for Resident #26, revealed the resident had intact cognition. Review of the care plan for Resident #26 revealed areas of focus for risk for nutrition and skin integrity. Review of the physician's orders dated 07/02/23. 08/02/23 and 09/06/23 for Resident #26 , revealed the resident was ordered to receive Derma infusion protocol for DRIPT IV nurse via IV one-time monthly 500 mLs of 0.9 % NS at rate of 250 mLs an hr. (total additive volume of 30.4 mLs) Additive formula: Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 100 mgs, vitamin C (ascorbic acid) 5 gms, Vitamin B5 (Dexpanthenol) 250 mgs, Vitamin B6 (Pyridoxine) 4 mgs, Vitamin B12 (Methylcobalamin) 2 mgs, Vitamin B7 (Biotin) 20 mg, Magnesium Chloride 900 mgs, Calcium Chloride 200 mgs, Gluconate 200 mg, Zinc 10 mgs and Amino blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mg Taurine 100 mgs, and Glycine 100 mg) every month for micronutrient hydration therapy. Review of the MARs for Resident #26 revealed the resident received the physician ordered infusions on 07/07/23, 08/02/23, and 09/06/23. 3) Review of medical record for Resident #36 revealed the resident was admitted on [DATE]. Diagnoses included non-traumatic brain dysfunction, anemia hypertension, peripheral vascular disease (PVD), GERD, diabetes, hyperlipidemia, Alzheimer's disease, dementia, and asthma. Review of the MDS assessment dated [DATE] for Resident #36 revealed the resident had intact cognition. Review of the Care Plan for Resident #36 revealed areas of focus for risk for nutrition and skin impairment. Review of the physician's ordered dated 06/09/23 and 09/06/23 for Resident #36 revealed the resident was ordered to receive Derma infusion protocol for DRIPT IV nurse via IV one-time monthly 500 mLs of 0.9 % NS at rate of 250 mLs an hr. (total additive volume of 30.4 mLs) Additive formula: Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 100 mgs, vitamin C (ascorbic acid) 5 gms, Vitamin B5 (Dexpanthenol) 250 mgs, Vitamin B6 (Pyridoxine) 4 mgs, Vitamin B12 (Methylcobalamin) 2 mgs, Vitamin B7 (Biotin) 20 mg, Magnesium Chloride 900 mgs, Calcium Chloride 200 mgs, Gluconate 200 mg, Zinc 10 mgs and Amino blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mg Taurine 100 mgs, and Glycine 100 mg) every month for micronutrient hydration therapy. Review of the MARs for Resident #36, revealed the resident received the physician ordered infusions on 06/09/23 and 09/06/23. Interview with Resident #36 on 12/04/23 at 11:22 A.M. revealed no concerns related to the IV (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 12 of 15 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 12/21/2023 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 0837 services received from DRIPT-IV. Level of Harm - Minimal harm or potential for actual harm 4) Review of medical records for Resident #23 revealed an admission date of 07/18/15. Diagnoses included coronary artery disease, hear failure, hypertension, Peripheral vascular disease, anxiety, asthma, hyperlipidemia, and Alzheimer's disease, Residents Affected - Some Review of the MDS assessment dated [DATE] for Resident #23, revealed the resident had severely impaired cognition. Review of the physician's ordered dated 07/07/23, 08/02/23 and 09/06/23 for Resident #23 revealed the resident was ordered to receive Derma infusion protocol for DRIPT IV nurse via IV one-time monthly 500 mLs of 0.9 % NS at rate of 250 mLs an hr. (total additive volume of 30.4 mLs) Additive formula: Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 100 mgs, vitamin C (ascorbic acid) 5 gms, Vitamin B5 (Dexpanthenol) 250 mgs, Vitamin B6 (Pyridoxine) 4 mgs, Vitamin B12 (Methylcobalamin) 2 mgs, Vitamin B7 (Biotin) 20 mg, Magnesium Chloride 900 mgs, Calcium Chloride 200 mgs, Gluconate 200 mg, Zinc 10 mgs and Amino blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mg Taurine 100 mgs, and Glycine 100 mg) every month for micronutrient hydration therapy. Review of MARs revealed Resident #23 received the physician ordered infusions on 07/07/23, 08/02/23, and 09/06/23. Interview with the Administrator and the Director of Nursing (DON) on 12/04/23 revealed they were unaware that the ancillary provider (DRIPT IV) did not possess a Terminal Distributor of Dangerous Drugs (TDDD) license for the State of Ohio when they provided IV services to the facility. The DON verified that the above listed residents received IV infusions provided by the ancillary provider. Interview with Regional Clinical Director (RCD) #600 on 12/05/23 at 2:15 P.M. revealed on 11/14/23 the Administrator from their sister facility ([NAME] of Middletown) notified them that DRIPT IV was no longer servicing the Ohio market and there was no additional information provided as to the reasoning. RCD #600 reported that all of the residents were assessed and any changes in conditions were discussed on a daily basis and there were no issues noted. Registered Nurse #110 with the interdisciplinary team (IDT) was assigned to do the resident record reviews. RCD #600 reported their Corporate Chief Executive Officer (CEO) # 115 educated the Administrators, Regional Nurses, and Regional Administrators of the requirement to verify the TDDD for all vendors. RCD #600 reported medication education occurred on 11/09/23 that was related to a similar situation to the findings of another complaint survey, and the training was appropriate for both the previous complaint and the current investigation. RCD #600 stated that the clinical documentation for all residents who received DRIPT therapy was reviewed for any negative outcomes or undesirable results. Attempts to interview Medical Director (MD) #100 on 12/07/23 and 12/12/23 were unsuccessful. Interview with Representative #405 for the ancillary provider stated they did not have State of Ohio TDDD licensure. He stated they were a Medical Entity, with a Medical Director licensed in the State of Ohio. Every other state in which they provided services did not require a special TDDD license and after about three months of providing services in the Ohio area, they learned Ohio was an exception. He stated they applied for the license and were told they could continue providing services, license approval would take days. He stated an audit was conducted, and the Board of Pharmacy reported them. Simultaneously, the group had decided to stop providing services in Ohio unrelated to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 13 of 15 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 12/21/2023 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 0837 Level of Harm - Minimal harm or potential for actual harm licensure concerns. They rescinded their application for licensure. He stated they provided five specialized infusions that could be specialized based on resident needs. The intervention was created a couple of years ago and found to be beneficial for residents with chronic urinary tract infections (UTI), residents who did not eat or drink well, and/or weight loss concerns. He stated they presented the program to facility ownership. Residents Affected - Some Interview with the facilities General Counsel #406 stated studies had shown hydration therapy improved and reduced risk of dehydration and rehospitalization. General Counsel #406 stated she learned of this licensing concern on 11/14/23 and had contacted the General Counsel for the ancillary provider who reported when they started the process in Ohio, they had been told they did not require TDDD license for Ohio. They reported they were initially told by the Board of Pharmacy they did not require an Ohio license, there were a ton of exemptions. They reported they applied for the license. General Counsel #406 stated the provider did not explain concerns with licensure when they announced they were no longer providing services. It was explained as a decrease in services related to rate freezes. General Counsel #406 stated she was not involved with the initial vetting process and could not provide specific information as to the steps involved in the approval. The corporation had started a compliance investigation on this with a compliance officer specific to this incident. General Counsel #406 revealed the contract had been signed on 12/09/22 by their Chief Financial Officer (CFO). The General Counsel at that time would have gone through a legal review with a multi-layered vetting process before it was presented to the CFO. She was in the process of investigating everything involved in the process and was still gathering information. Review of the State of Ohio Terminal Distributor Licensure of Prescriber Practices (https://www.pharmacy.ohio.gov), dated 08/24/23, revealed a TDDD license allows a business entity to purchase, possess, and/or distribute dangerous drugs at specific locations. Terminal distributors of dangerous drugs include, but are not limited to, hospitals, pharmacies, Emergency Medical Services (EMS) organizations, laboratories, nursing homes, and prescriber practices. Distribution includes the administration of drugs on-site to patients as well as providing medications to patients to take away from the facility for later use. Dangerous drugs are defined in the Ohio Revised Code as any drug that meets any of the following: 1. Requires a subscription; 2. Bears on the label a Federal Legend (Rx Only or Caution: Federal law prohibits dispensing without a prescription); 3. Is intended for injection into the human body; or 4. Any drug that is a biological product as defined in section 3715.01 of the Revised Code. Ohio Revised Code (ORC) 4729.51 states that no licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor shall sell dangerous drugs to anyone other than the following: (1) a licensed terminal distributor of dangerous drugs; (2) Any person exempt from licensure as a terminal distributor of dangerous drugs under section 4729.541 of the Revised Code (3) a licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor; or (4) A terminal distributor, manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor that is located in another state, is not engaged in the sale of dangerous drugs within this state, and is actively licensed to engage in the sale of dangerous drugs by the state in which the distributor conducts business. In general, the exemptions to Ohio's TDDD licensure requirements do not apply if the prescriber practice is engaged in drug compounding. Compounding is defined as the preparation, mixing, assembling, packaging, and labeling of one or more drugs. Compounding includes the combining, admixing, diluting, reconstituting, or otherwise altering of a drug or bulk drug substance. The deficiency was corrected on 11/19/23 after the facility implemented the following corrective actions: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 14 of 15 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 12/21/2023 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 0837 On 09/06/23 was the last utilization of services from DRIPT IV. Level of Harm - Minimal harm or potential for actual harm On 09/22/23, the contract with DRIPT IV cessation was effective. Residents Affected - Some On 11/14/23, the facility was notified that DRIPT IV solution vendor company who serviced the facility did not have a TDD licensure required in Ohio to dispense drugs. The Corporate attorney and Corporate Director of Procurement were notified by the RCD #600 On 11/15/23, all current residents who received DRIPT IV services were audited by RN #110 for change of condition related to receiving IVs from DRIPT IV and no issues were found. On 11/15/23, the governing body policy was revised and adopted by the Quality Assurance Performance Improvement (QAPI) committee during their meeting. On 11/15/23, the QAPI Committee was educated on the governing body policy by Corporate. On 11/15/23, the QAPI Committee will review any new contracts via the QAPI committee to ensure licensure is validated and compliant with the governing policy. The QAPI committee will meet monthly as needed. On 11/15/23, the Administrator and/or the DON will be responsible for monitoring on going compliance. On 11/19/23, all licensed nurses were educated on the medication administration and medication documentation by RN #100 Review of four Residents (#01, #09, #11, and #12) medical records revealed assessments were completed. This deficiency represents non-compliance investigated under Complaint Number OH00148166. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 15 of 15