Inspection·September 9, 2024

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many facility failed to notify the Public Health Department or implement the Water Management Plan immediately following notification of Resident #10's new diagnosis of Legionella. Interview on 08/29/24 at 4:45 P.M., with the Director of Nursing (DON) confirmed the facility was aware of Resident #10's new diagnosis of Legionella on 08/19/24, when the faxed paperwork was given to them by the Admissions Director. Interview on 09/09/24 at 9:00 A.M., with the Assistant Director of Nursing (ADON) #200 verified the facility did not begin notifying residents and families about the Legionella infection or potentially contaminated water until 08/26/24. This deficiency represents noncompliance investigated under Complaint Number OH00157404. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 2 of 7 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 09/09/2024 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)

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, review of letter from Administrator, review of email correspondence from the local health department, policy reviews, review of water temperature audits, review of Environmental Assessment of Water Systems report, review of the third -party consultant action plan, review of infection control logs, review of contract with a Water Management Consultant Company and staff interviews, the facility failed to implement a water management program to prevent Legionella in the water system and report a case of Legionella to the local authorities. This affected one (#10) of three residents reviewed for Legionella and had the potential to affect all 149 residents residing at the facility. The facility census was 149. Residents Affected - Many Findings include: Review of Resident #10's medical record revealed an admission date of 07/04/24. Resident #10 was discharged to the hospital on [DATE] and returned to the facility on [DATE]. His diagnoses included: morbid obesity, essential hypertension, Legionnaires disease, cellulitis of lower limb, anemia, and pressure ulcer. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed he was cognitively intact. Further review of the MDS assessment revealed Resident #10 was dependent on staff for medication administration, toileting, personal hygiene, and he required assistance from staff with eating, and oral hygiene. Review of the Resident #10's hospital progress notes, dated 08/15/24, verified Resident #10 had a positive urine test for Legionella. Further review of the hospital progress notes confirmed the facility was notified of the illness on 08/19/24 at 8:05 A.M. Review of the nursing progress notes for August 2024 for Resident #10 revealed no indication of the Legionnaires disease diagnoses including family or physician notification. Review of the electronic communication from the Public Health Department, dated 08/26/24 at 2:09 P.M., revealed the public health department emailed the facility management team including the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Infection Control Prevention (ICP) Nurse #165 to notify and discuss a confirmed case of Legionella at the facility. Review of the electronic communication between the DON and the laboratory (lab) confirmed the Legionella test for Resident #10, dated 08/28/24 at 12:01 P.M., verified the lab ran a rapid test to determine the presence of Legionella on Resident #10 and the results were positive. Interview on 08/29/24 at 12:47 P.M., with the Assistant Director of Nursing (ADON) #200 revealed the facility was notified from [NAME] County Health Department via email communication dated 08/26/24 of Resident #10's diagnoses of Legionella. ADON #200 confirmed on 08/26/24 when the facility was notified, the facility immediately stopped utilizing the water and utilized bottled water for care, drinking, and bed baths. The ADON #200 stated the facility was not aware of the diagnoses until she received the email from the health department. ADON #200 stated the facility was not notified of Resident #10's diagnoses from the hospital even at discharge from the hospital to admission to the nursing facility. ADON #200 confirmed nothing was written in Resident #10's medical chart relates to the Legionella diagnoses because the facility was not notified of the diagnoses from the hospital. ADON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 3 of 7 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 09/09/2024 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many #200 confirmed Resident #10 received treatment for the Legionella Diagnoses in the hospital, however, she stated Resident #10 has many comorbidities that the same antibiotics could have been used to treat Legionella. Interview on 08/29/24 at 1:37 P.M., with the Administrator, Director of Nursing (DON), and ADON revealed ADON #200 stated she has a separate file that has the documentation of Resident #10's diagnoses and confirmed it is not located in his medical chart. The Administrator, DON, and ADON #200 continued to confirm the diagnoses was not made available to the facility until the local health department contacted the facility via email on 08/26/24. The DON stated the facility would not have been made aware of the diagnosis because Resident #10 received treatment at the hospital for Legionella and he is alert and oriented. The DON insisted the hospital would not have provided the information related to the Legionella diagnoses because they treated it at the hospital. The DON stated there would be no reason to notify Resident #10, his family member, or the physician of the Resident at the facility because treatment was done at the hospital. Interview on 08/29/24 at 1:49 P.M., with the DON and ADON #200 on 08/29/24 at 1:49 P.M. confirmed the facility did not document the new diagnoses of Legionella in Resident #10's medical chart because Resident #10 was aware of what he was tested and treated for. ADON #200 confirmed the Legionella Diagnoses was listed on his hospital paperwork, however, it was not documented as a new diagnosis and the facility wasn't sure if it was an old or new diagnoses. Interview on 08/29/24 at 3:30 P.M., with Infection Control Prevention (ICP) Nurse #165 confirmed the facility failed to notify the Public Health Department or implement the Water Management Plan immediately following notification of Resident #10's new diagnosis of Legionella. ICP #165 stated the facility was aware of Resident #10's new diagnosis of Legionella Disease when the paperwork from the hospital was faxed to the facility on [DATE]. ICP #165 stated any time a resident return from the hospital with an antibiotic he will research the why and list it in the infection control map and binder. ICP #165 verified all of management was aware when Resident #10 returned to the facility with a new diagnosis of Legionella, however, no one was sure what steps the facility should take. ICP #165 confirmed it was not until after the Local Health Department notified the facility on 08/26/24, that the facility acted and corporate sent over the report titled, Environmental Assessment of Water Systems and the facility hired the third-party consultants for an action plan. The ICP #165 stated the facility did not act because the facility felt it did not come from the facility until they were notified by the local health department. Interview on 08/29/24 at 4:45 P.M., with the DON confirmed the facility was aware of Resident #10's new diagnosis on 08/19/24 when the faxed paperwork was given to them by the Admissions Director. Review of the facility infection control log and map of infections confirmed Resident #10 was listed on 08/22/24 with a new diagnosis of Legionella. Review of the facility contract with a Water Management Consultant Company was signed on 08/26/24, by the Administrator and consultant. However, the contract's effective date was listed as 08/28/24. Review of the letter of notification mailed to the resident's family from the Administrator, dated 08/27/24, revealed the facility had worked with the Public Health Department and a third -party consultant company to take the appropriate steps to ensure the safety of the residents. The letter stated water samples had been taken and sent to a Centers for Disease Control and Prevention (CDC) laboratory for testing and sample results are pending. Further review of the family notification letter (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 4 of 7 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 09/09/2024 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many stated the facility will have the consulting team on sight and in various resident rooms and common areas to complete a water system risk assessment and provide recommendations on 08/27/24. The letter confirmed the facility will apply all appropriate safeguards and recommendations as identified. Review of the facility report titled, Environmental Assessment of Water Systems, hand dated 08/20/24 at 11:20 A.M., completed by ICP#165 revealed the description of the facility was blank on page 3. On page 4 of the assessment, it was determined the facility does have a fountain or water decoration, however the location and description were left blank. Further review of the facility Water System assessment revealed the facility water temperatures ranged from 105 Fahrenheit (F) and 120 F; however, the dates of measurement were left blank on Page 5. Page. 6 of the facility Water System assessment was blank including documentation of the facility thermostatic mixing valve. Page 7 through 13 were left blank and no facility assessment was completed of the Water System. Review of the facility audit titled, Water Temperature Audit, dated April 2024 through present date, revealed water temperatures ranged from 109F to 142 F. No verification of water temperatures January 2024 through April 2024 was provided. Review of the third -party consultant action plan stated the following steps will take place, Step one: Notify the physician, the local health department, and the Ohio Department of Health. Step 2. Notify all residents, family members, responsible parties, and staff and document in the resident's chart. Step 3. Notify the owner of the building. Step 4. Activate the facility's emergency water policy. Step 5. Post signage on all water outlets. Step 6. Post signage at all points of entry into the facility. Step 7. Utilize bag iced and bottles of water. Step 8. Contact the lab and document the result of the discussion. Step 9. Initiate a line listing of the past six months of pneumonia, and review findings with the medical director. Step 10. Begin heightened environmental and clinical monitoring. Step 11. Review the facility Legionella Risk Assessment and correct any short comings. Step 12. Review the facility water management plan. Step 13. Begin discussion with industrial water management to complete remediation. Step 14. Review concerns with other water pathogens. Step 15. Social Services is to complete a wellness relative to the resident's psycho- social wellbeing. Step 16. Formalize revisions to the Water Management program and notify residents of the changes. Step 17. Post remediation sampling every two weeks for three months. If no Legionella is produced during the second three-month period, then the testing can be reduced to quarterly. Step 18. If the environmental sampling is produces positive Legionella results, isolates should be typed and saved. Step 19. Continue heightened physical environment and clinical monitoring. Review of the undated policy titled, Legionella Surveillance and Detection, indicated the facility included Legionella as part of the infection surveillance activities. The clinical staff will be trained on how to identify signs and symptoms and notify the physician immediately if Legionnaire's disease is suspected. Further review of the policy confirmed if Legionella is detected in one or more residents, then the Infection Preventionist will activate the surveillance for Legionnaire's Disease, notify the local health department, notify the Administrator and Director of Nursing, and an investigation into the possible source of contamination will be initiated. Review of the policy titled, Legionella Water Management Program, dated July 2017, indicated the facility has a water management program overseen by the water management team. The team consisted of the Administrator, the Infection Preventionist, the Medical Director (or designee), the Director of Maintenance, and the Director of Environmental Services. The purpose of the water management teams is to reduce the risk of Legionnaires disease. Further review of the policy revealed the facility water management program is based on the Centers for Disease Control and Prevention (CDC) and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 5 of 7 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 09/09/2024 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHARE) recommendations. The facility water program consists of a detailed diagram and description of the water system, the identification of areas in the water system that could permit Legionella or other bacteria to grow, the identification of situations that can lead to Legionella growth, specific measures used to control the introduction or spread of the disease, and how often the water management team will meet. Residents Affected - Many This deficiency represents noncompliance investigated under complaint numbers OH00157504, OH00157484, OH00157442, OH00157404, and OH00157265. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 6 of 7 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 09/09/2024 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)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to provide a sanitary and comfortable environment for the residents, staff and public. This had the potential to affect the residents residing on the memory care unit, 200 and 300 halls. Census was 149. Findings include: Observations on 09/04/24 and 09/05/24, revealed discolored ceiling tiles and dark discoloration near sprinkler and sensor located in the ceiling in the 300 hallway. Interview on 09/05/24 at 6:35 A.M., with Licensed Practical Nurse (LPN) #175 verified the discolored ceiling tiles. Observations on 09/04/24 and 09/05/24, revealed discolored ceiling observed near the light fixture and fire sensor outside room [ROOM NUMBER]. Interview on 09/05/24 at 7:02 A.M., with LPN #175 verified the discolored ceiling tiles. Observations on 09/04/24 and 09/05/24, revealed dark discoloration surrounding orange colored growth on ceiling tiles in the hallway outside of the 200 hall nurses' station and discoloration on multiple ceiling tiles and covering for ceiling light fixture outside of the 200A nurses station. Interview on 09/05/24 at 7:00 A.M., with LPN #175 verified the discolored ceiling tiles. Interview on 09/05/24 at 7:02 A.M., with LPN #172 revealed the dark stains on ceiling tiles near 200 hall nurses' station are common due to water leaks from ceiling. LPN #172 stated the facility place containers on the floor under the leaks to catch the water. Observations on 09/04/24 and 09/05/24, revealed discolored ceiling tiles near rooms [ROOM NUMBERS]. Interview on 09/05/24 at 7:05 A.M., with LPN #175 verified the discolored ceiling tiles. Observations on 09/04/24 and 9/05/24, revealed discolored ceiling tiles and a bowed-out ceiling tile with brown stain in the memory unit dining area. Wet floor sign located below the bowed ceiling tile. Interview on 09/05/24 at 7:26 A.M., with LPN #193 verified the discolored ceiling tiles. Interview on 09/05/24 at 10:40 A.M., with LPN #180 revealed there is a hole in the ceiling of memory unit nurses' station and mold on the ceiling because the ceiling leaks frequently. LPN #180 stated a bucket is placed on the floor when leaks occur. This deficiency represents noncompliance investigated under Complaint Number OH00156369. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 7 of 7