Inspection·February 1, 2024

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, resident interview, review of resident council meeting minutes, and policy review, the facility failed to ensure food was served warm and palatable. This had the potential to affect all but two (#27 and #93) residents who did not receive food from the facility's kitchen. The facility census was 150. Residents Affected - Some Findings include: Observation of the kitchen on 02/01/24 at 8:20 A.M. revealed a test tray went out on the 2B unit cart. All trays were retrieved from the meal cart on 07/03/23 at 8:34 A.M. The scrambled eggs, served on a Styrofoam plate and covered with an insulated lid, were 110 degrees Fahrenheit and cold to taste. Interview on 02/01/24 at 8:35 A.M., Account Manager (AM) #315 verified the scrambled eggs were cold and not palatable. AM #315 further stated the facility's dishwasher had been out since 12/22/23 and the facility often had to serve on disposable dinner ware. Interview on 02/01/24 at 10:11 A.M. Resident #69 stated the food was usually served cold. Interview on 02/01/24 at 10:21 A.M., Resident #52 stated the food was often served cold. Interview on 02/01/24 at 10:28 A.M., Resident #75 stated the food is always served cold. Interview on 02/01/24 at 10:44 A.M., Resident #17 stated the food was only sometimes hot enough and further stated the eggs were not hot that morning. Interview on 02/01/24 at 10:45 A.M., Resident #22 stated the food was not hot enough and always luke warm. Review of the resident council meeting minutes dated 12/20/23 revealed the residents stated the food was cold on trays. Review of the resident council meeting minutes dated 01/25/24 revealed the residents stated food can be cold on trays. Review of the facility policy titled, Food: Quality and Palatability, dated 02/2023, revealed food was to be served palatable, attractive, and served at a safe and appetizing temperature. This deficiency represents non-compliance investigated under Complaint Number OH00150427. 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 2 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 02/01/2024 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)