Inspection·May 5, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few were enough chairs. LPN #106 verified not all residents go to the dining room to eat, some residents sit in their wheelchairs while eating and she could have found another chair for Resident #38 if necessary. LPN #106 verified the small dining room on [NAME] Lane Hall could be used by other residents. She reported she had told Resident #38 he could not eat in the small dining room. Interview on 05/03/23 at 12:45 P.M. with Resident #38 revealed a couple of weeks ago he wanted to sit in the small dining room on [NAME] Lane Hall. He reported the main dining room was closed and he did not want to eat in his room. He reported he walked into the small dining room and before he could sit down, LPN #106 told him he was not allowed to eat in the small dining room because he did not live on [NAME] Lane Hall. Resident #38 reported at the time her words were very upsetting to him. He did not think she spoke to him respectfully. He denied she was verbally abusive to him. Interview on 05/04/23 at 2:24 P.M. with the DON revealed she was aware of a situation with Resident #38 and LPN #106. She reported Resident #38 brought it to her attention and she informed LPN #106 that Resident #38 had a right to sit in the small dining room and the facility should be respectful of his wishes. The DON revealed her conversation with Resident #38 revealed the way he was spoken to and treated by LPN #106 really bothered him. Review of the Resident Council Meeting Minutes dated 04/17/23 revealed Resident #38 complained about a nurse always being on his case. Review of facility undated policy titled, Dignity, Respect and Privacy revealed the policy purpose was to provide care to residents while maintaining their dignity and privacy. Residents were to always be treated with respect and cared for in a manner that protected their privacy. Their individual preferences were to be evaluated and reasonable accommodations made, and care and treatment were to be delivered in a way that maintained their dignity at all times. This deficiency represents non-compliance investigated under Complaint Number OH00142359. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 2 of 14 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 365578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of New Lexington 920 South Main Street New Lexington, OH 43764 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 Based on record review and interview the facility failed to ensure Resident #3 and Resident #4, who required staff assistance for activities of daily living received necessary and timely assistance with showers. This affected two residents (#3 and #4) of three residents reviewed for showers. The facility census was 61. Residents Affected - Few Findings included: 1. Review of Resident #3's medical record revealed an initial admission date of 06/30/22 with diagnoses including paraplegia, type two diabetes, acquitted absence of left leg above the knee, hemiplegia and hemiparesis following cerebral vascular disease, and essential hypertension. Review of Resident #3's plan of care, dated 07/07/22, revealed he had paraplegia related to a spinal injury. Interventions included assist with activities of daily living and locomotion as required. Encourage the resident to perform as much as possible of these activities. Review of Resident #3's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/14/23 revealed the resident was cognitively intact. The assessment indicated the resident required extensive assistance of two people for personal hygiene. The MDS indicated Resident #3 did not present with any physical, verbal , or other behavioral symptoms nor did he reject care. Review of Resident #3's shower care documentation for February 2023 revealed he received shower/bathing on 02/10/23, 02/19/23, and 02/26/23. There were no documented refusals of shower/bathing for February 2023. Review of the shower documentation for March 2023 revealed the resident received shower/bathing on 03/09/23, 03/19/23, and 03/22/23. There was one documented refusal for a shower on 03/11/23. Review of Resident #3's shower care documentation for April 2023 revealed the resident received shower/bathing on 04/10/23. There was one documented refusal for a shower/bathing on 04/04/23. Interview on 05/03/23 at 5:20 A.M. with Licensed Practical Nurse (LPN) #105 revealed showers were not always provided for the residents who need two staff to assist due to staffing issues. Interview on 05/03/23 at 5:25 A.M. with Registered Nurse (RN) #104 revealed residents who need two staff to assist with showers were not getting their showers. Interview on 05/03/23 at 5:32 A.M. with State Testing Nursing Assistant (STNA) #101 revealed showers were an issue for a while, but they were better now. She reported it was not that the STNAs were not doing their job, she stated the facility was just short staffed. Interview on 05/03/23 at 5:42 A.M. with STNA #102 revealed there were residents who were not getting showers. She reported it was not that the staff do not try to give showers, there just were not enough staff. Interview on 05/03/23 at 5:51 A.M. with STNA #103 revealed showers were not always getting done for the residents who need two staff to assist due to not having enough staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 3 of 14 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 365578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of New Lexington 920 South Main Street New Lexington, OH 43764 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 05/03/23 at 7:50 A.M. with LPN #106 revealed if the shower aide was not pulled to work the floor, then showers were provided, However, if a floor aide called off, the shower aide may be pulled and then showers were not completed. Interview on 05/03/23 at 8:45 A.M. with Resident #3 revealed he did not receive showers like he was supposed to, but stated the staff had been doing better recently. The resident reported he was not sure why he did not get his showers. On 05/04/23 at 2:05 P.M. interview with the Director of Nursing (DON) and Registered Nurse #9 revealed there was no additional documentation regarding showers for Residents #3. The DON and RN #9 verified Resident #3 had not received showers as planned during the timeframe reviewed above. 2. Review of Resident #4's medical record revealed an initial admission date of 04/10/18 and a readmission dated 04/27/19 with diagnoses including malignant neoplasm of the lower lobe of the lung, hemiplegia and hemiparesis following a cerebral infarction, and essential hypertension. Review of Resident #4's plan of care, dated 08/30/19 revealed the resident had activity of living deficits related to history of fall with left femur fracture, chronic obstructive pulmonary disease, left side hemiparesis, non-ambulatory, and lung cancer. Interventions included bath and showers per request and as needed. Skin check, shower, shampoo hair, nail care and lotion as needed. Provide weight bearing assistance up to total dependent care with bathing, dressing, and transfers. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/10/23, revealed the resident was cognitively intact. The assessment indicated she required extensive assistance of one person to physically assist with personal hygiene. The MDS indicated Resident #4 did not present with any physical, verbal , or other behavioral symptoms nor did she reject care. Review of Resident #4's progress note, dated 04/17/23 revealed the resident had the ability to bathe self, including washing, rinsing, and drying self. She was not able to wash her back or hair. She was dependent on staff for transferring in and out of the tub/shower. Review of Resident #4's shower care documentation for February 2023 revealed the resident received showers/bathing on 02/10/23, 02/14/23, and 02/24/23. There were no documented refusals of showers for February 2023. Review of her shower documentation for March 2023 revealed the resident received showers/bathing on 03/06/23, 03/10/23 and 03/13/23. There were two documented refusals for showers on 03/09/23 and 03/28/23. Review of Resident #4's shower documentation for April 2023 revealed the resident received showers/bathing on 04/03/23, 04/05/23, 04/07/23, 04/17/23, 04/19/23, 04/26/23, and 04/28/23. There were no documented refusals of showers for April 2023. Interview on 05/03/23 at 5:20 A.M. with Licensed Practical Nurse (LPN) #105 revealed showers were not always provided for the residents who need two staff to assist due to staffing issues. Interview on 05/03/23 at 5:25 A.M. with Registered Nurse (RN) #104 revealed residents who need two staff to assist with showers were not getting their showers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 4 of 14 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 365578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of New Lexington 920 South Main Street New Lexington, OH 43764 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 05/03/23 at 5:32 A.M. with State Testing Nursing Assistant (STNA) #101 revealed showers were an issue for a while, but they were better now. She reported it was not that the STNAs were not doing their job, she stated the facility was just short staffed. Interview on 05/03/23 at 5:42 A.M. with STNA #102 revealed there were residents who were not getting showers. She reported it was not that the staff do not try to give showers, there just were not enough staff. Interview on 05/03/23 at 5:51 A.M. with STNA #103 revealed showers were not always getting done for the residents who need two staff to assist due to not having enough staff. Interview on 05/03/23 at 7:50 A.M. with LPN #106 revealed if the shower aide was not pulled to work the floor, then showers were provided, However, if a floor aide called off, the shower aide may be pulled and then showers were not completed. Interview on 05/03/23 at 8:25 A.M. with Resident #4 revealed there was a time when she was not getting her showers because the facility did not have enough staff and she needed two staff to assist her. She reported the facility needed more staff. Interview on 05/03/23 at 9:12 A.M. with STNA #108 revealed when the facility was short staffed, it was difficult to get the showers completed and the residents were the ones who suffer. On 05/04/23 at 2:05 P.M. interview with the Director of Nursing (DON) and Registered Nurse #9 revealed there was no additional documentation regarding showers for Residents #4. The DON and RN #9 verified Resident #4 had not received showers as planned during the timeframe reviewed above. Review of a list provided by the facility revealed one resident was independent for showers, 44 residents required assistance with showers and 16 residents were dependent on staff for showers. Further review of the list revealed of the 44 residents who required assistance, 11 required two staff to assist with transfers. This deficiency represents non-compliance investigated under Complaint Number OH00142359. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 5 of 14 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 365578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of New Lexington 920 South Main Street New Lexington, OH 43764 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview the facility failed to provide vascular wound care treatments for Resident #16 as ordered and in a manner to promote healing and inhibit infection. This affected one resident (#16) of one resident reviewed for vascular wounds. The facility census was 61. Residents Affected - Few Findings Include: Review of Resident #16's medical record revealed an admission date of 03/15/23 with diagnoses including chronic obstructive pulmonary disease, cellulitis of the left lower limb, and essential hypertension. Review of Resident #16's admission Minimum Data Set (MDS) 3.0 assessment, dated 03/22/23, revealed the resident had intact cognition. The assessment revealed she had three venous and arterial ulcers, surgical wounds, and needed application of nonsurgical dressing other than to feet, application of ointments/medication other than to feet, and application of dressings to feet. Review of Resident #16's plan of care, dated 04/03/23, revealed she had a potential/actual impairment to skin integrity related to surgical incisions, cellulitis, peripheral vascular disease, and fragile skin. Interventions included encouraging medication and treatment regimen. Review of Resident #16's physician order, dated 04/26/23 to current, identified an order for bilateral feet/toes/heels, paint all dry necrotic areas with Betadine three times weekly and as needed. Review of Resident #16's physician order, dated 04/26/23 to current, identified an order for her right inner thigh: cleanse with normal saline or wound cleanser, cover open area with silver alginate, cover with foam dressing and change three times weekly and as needed. Review of Resident #16's physician order, dated 04/26/23 to current, identified an order for her right plantar 4th and 5th toes: apply Betadine moistened gauze to open area. Cover with ABD and wrap loosely with gauze. Do not apply too tight and change three times weekly and as needed. Review of Resident #16's physician order, dated 04/17/23 to 04/26/23, identified an order for her right inner thigh: cleanse with normal saline or wound cleanser, cover open area with Alginate Ag (silver) cover with foam dressing, change every day and as needed. Review of Resident #16's physician order, dated 04/11/23 to 04/26/23, identified an order for her bilateral feet/toes/heels to paint all dry necrotic areas with Betadine and leave open to air. Review of Resident #16's physician's orders, dated 03/17/23 to 04/10/23, identified an order to cleanse right lateral lower leg with wound cleanser and pat dry, cover with a dry, clean dressing if draining, may leave open to air, 10 staples intact. Review of Resident #16's physician's orders, dated 03/17/23 to 04/10/23, identified an order to cleanse surgical incision above right knee with wound cleanser, pat dry, leave open to air if no drainage, three staples intact. Review of Resident #16's physician's orders, dated 03/17/23 to 04/10/23, identified an order to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 6 of 14 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 365578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of New Lexington 920 South Main Street New Lexington, OH 43764 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cleanse surgical incision to front of thigh with wound cleanser, pat dry, cover with dry, clean dressing until resolved., eight staples intact. Review of Resident #16's physician's orders, dated 03/16/23 to 04/10/23, identified an order for left inner thigh incision - cleanse with normal saline, pat dry, cover with dry, clean dressing if draining. May leave open to air if not draining. Review of Resident #16's physician order, dated 03/16/23 to 04/10/23, identified an order for bilateral feet/toes/heels paint all dry necrotic areas with Betadine and leave open to air. Review of Resident #16's physician's orders, dated 03/16/23 to 04/10/23, identified an order for left lateral heel pain with Betadine and cover with dry, clean dressing if draining. Review of Resident #16's physician's orders, dated 03/15/23 to 04/26/23, identified an order for right plantar 4th and 5th toes, apply Betadine moistened gauze to wound and between toes. Cover with dry gauze and wrap loosely with gauze. Do not apply too tight. Review of Resident #16's Treatment Administration Record (TAR) for 03/2023 and 04/2023 revealed she did not receive treatments as ordered for her feet and toes on 03/22/23, 03/27/23, 04/10/23, 04/11/23, and 04/26/23; for her right inner thigh on 03/22/23, 03/27/23, 04/10/23, and 04/26/23; for her right lateral leg on 03/22/23, 03/27/23, and 04/10/23; for her surgical incision above the right knee on 03/22/23, 03/27/23, and 04/10/23; for her surgical incision to her front thigh on 03/22/23, 03/27/23, and 04/10/23; for her left inner thigh incision on 03/22/23, 03/27/23, and 04/10/23; for her left lateral heel on 03/22/23, 03/27/23, and 04/10/23; and for her right planter foot at 4th and 5th toes on 03/22/23, 03/27/23, 04/11/23, and 04/26/23. Interview on 05/03/23 at 5:51 A.M. with State Tested Nurse Aide (STNA) #103 revealed she did not do wound treatments but had heard Resident #16 was not getting treatments as ordered. Interview on 05/04/23 at 11:54 A.M. with Registered Nurse (RN) #109 verified there was no documentation to support the treatments were completed for Resident #16 for the dates with no documentation on the TAR. She verified treatments should be done as ordered by the physician. In addition, on 05/04//23 at 9:30 A.M. Licensed Practical Nurse (LPN) #106 was observed providing wound treatment for Resident #16. LPN #106 collected her supplies, washed her hands and applied gloves. She then removed the dressing from the resident's right foot which was dated 05/03/23. She used wound cleanser to loosen the dried dressing from the wound bed. LPN #106 discarded the old dressing, removed her gloves, washed her hands, and applied new gloves. She cleaned the wounds per the physician order with Betadine solution. LPN #106 then removed her gloves and applied a new pair of gloves without first washing her hands. She applied the appropriate dressings to the wounds. LPN #106 then removed her gloves and washed her hands. Interview on 05/04/23 following wound care for Resident #16, LPN #106 verified she should have washed her hands after removing her gloves and applying new gloves. This deficiency represents non-compliance investigated under Complaint Number OH00142359. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 7 of 14 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 365578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of New Lexington 920 South Main Street New Lexington, OH 43764 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure Resident #3 and Resident #34 received pressure ulcer wound care treatments as ordered. This affected two residents (#3 and #34) of two residents reviewed for pressure ulcers. The facility census was 61. Residents Affected - Few Findings Include: 1. Review of Resident #3's medical record revealed an initial admission date of 06/30/22 with diagnoses including paraplegia, type two diabetes, acquitted absence of left leg above the knee, hemiplegia and hemiparesis following a cerebral vascular disease, and essential hypertension. Review of Resident #3's plan of care, dated 07/07/22, revealed he had one pressure ulcer and potential for more pressure ulcer development and impaired skin integrity related to paraplegia, decreased mobility, and anticoagulant use. Interventions included administering treatments as ordered and monitoring for effectiveness. Review of Resident #3's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/14/23, revealed the resident was cognitively intact. The assessment indicated he did not present with any physical, verbal , or other behavioral symptoms nor did she reject care. The assessment indicated he had a one Stage 4 (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI) pressure ulcer/injury on him. Review of Resident #3's physician's orders dated 01/16/23 to 02/18/23 revealed Dakins (1/4 strength) external solution 0.124 % (sodium Hypochlorite) apply to coccyx wound topically every day and night shift for Stage 4 coccyx wound. Cleanse with soap and water, pat dry, wet rolled gauze, pack wound with gauze, cover with ABD dressing and secure with hypafix. Apply to coccyx as needed for Stage 4 coccyx wound, may change for soiling or dislodgement. Review of Resident #3's physician's order dated 02/25/23 to 04/10/23 revealed an order for Dakins (1/4 strength) external solution 0.124 % (sodium Hypochlorite) apply to Stage 4 coccyx wound topically every shift cover with ABD dressing and hypafix. Review of Resident #3's physician's orders revealed an order, dated 04/10/23 for Dakins (1/4 strength) external solution 0.124 % (sodium Hypochlorite) apply to coccyx wound topically every shift, loosely pack with Dakins wet gauze, cover with an ABD dressing and hypafix. Review of Resident #3's Treatment Administration Record (TAR) for 02/23, 03/23, and 04/23 revealed he did not receive treatments as ordered on 02/10/23 (days), 03/23/23 (nights), 03/15/23 (days), 03/27/23 (days), 04/04/23 (days), 04/11/23 (days), 04/24/23 (days) and 04/28/23 (days). Interview on 05/04/23 at 11:54 A.M. with Registered Nurse (RN) #109 verified there was no documentation to support the treatments were completed for Resident #3 for the dates with no documentation on the TAR. She verified treatments should be done as ordered by the physician. 2. Review of Resident #34's medical record revealed an admission date of 12/09/22 with diagnoses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 8 of 14 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 365578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of New Lexington 920 South Main Street New Lexington, OH 43764 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few including malignant neoplasm of cervix, type two diabetes, essential hypertension, and Parkinson's disease. Review of Resident#34's plan of care dated 12/19/22 revealed she had one pressure ulcer or potential for pressure ulcer development related to terminal prognosis, cervical cancer, immobility, fragile skin, and incontinence. Interventions included administering treatments as ordered and monitoring for effectiveness. Review of Resident #34's physician's order dated 12/12/22 identified an order for daily monitoring of wound site to coccyx, monitor for signs and symptoms of infection and dry intact dressing. Notify provider if decline in wound was noted. Review of Resident #34's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/17/23 revealed the resident had intact cognition. The assessment indicated she presented no physical, verbal or other behaviors nor did she reject care. The assessment indicated she had a one Stage 3 (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) pressure ulcer/injury on her. Review of Resident 34's physician's orders dated 02/15/23 to 02/23/23 identified an order to cleanse coccyx with soap and water, pat dry and apply Medihoney every shift and as needed. Apply 4 x 4 gauze once Medihoney is applied and cover with a clean, dry dressing. Change as needed for soiling or dislodgment, monitor with each change for signs or symptoms of infection. Review of Resident 34's physician's orders dated 02/24/23 until 04/26/23 identified an order to clean coccyx with soap and water, pat dry and pack with Mesalt every day and as needed for soiling or dislodgement. Cover with a clean dry dressing, not a foam dressing Review of Resident 34's physician order dated 04/26/23 to current identified an order to cleanse coccyx with spray cleanser or normal saline. Loosely pack with silver alginate, cover with foam dressing. Change dressing daily and as needed. Review of Resident #34's Treatment Administration Record (TAR) for February 2023, March 2023, and April 2023 revealed she did not receive treatment as ordered on 02/23/23, 03/15/23, 03/27/23, or 04/27/23. Interview on 05/03/23 at 5:51 A.M. with STNA #103 revealed she did not do wound treatments but had heard Resident #34 was not getting treatments as ordered. Interview on 05/04/23 at 11:54 A.M. with RN #109 verified there was no documentation to support the treatments were completed for Resident #34 for the dates with no documentation on the TAR. She verified treatments should be done as ordered by the physician. This deficiency represents non-compliance investigated under Complaint Number OH00142359. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 9 of 14 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 365578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of New Lexington 920 South Main Street New Lexington, OH 43764 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, medical record review, staffing schedule review, review of the Centers for Medicare and Medicaid Census and Condition (CMS) Form 672, review of the facility staffing policy, and interviews, the facility failed to ensure there was adequate staffing to provide bathing for residents. This affected six residents (#3, #4, #25, #34, #52 and #57) and had the potential to affect all 61 residents residing in the facility. Findings include: On 03/31/23 at 5:01 A.M. the surveyor entered the facility to conduct the complaint investigation. Observation revealed there were three licensed nurses and three State Tested Nursing Assistants (STNA's) on duty to provide care for 61 residents currently residing in the facility. Review of the facility completed Centers for Medicare and Medicaid (CMS) Census and Condition form 672 revealed the facility provided Activities of Daily Living (ADL) information for 61 residents. The ADL information revealed the facility had one resident that was independent with bathing, six residents independent with dressing, seven residents independent with transferring, nine residents independent with toilet use and 43 residents independent with eating. The facility identified 44 residents who required the assistance of one or two staff for bathing and 16 residents who were totally dependent on staff for bathing. The facility identified 53 residents who required the assistance of one or two staff for dressing and 2 residents who were totally dependent on staff. The facility identified 42 residents who required the assistance of one or two staff for transferring and 12 residents who were totally dependent on staff. The facility identified 49 residents who required the assistance of one or two staff for toileting and three residents who were totally dependent on staff. The facility identified 17 residents who required the assistance of one to two staff for eating and one resident who was totally dependent on staff. 1. The following resident concerns were lodged during the complaint investigation related to facility staffing: a. Interview on 05/03/23 at 8:00 A.M. with Resident #57 revealed sometimes there was only one aide on nights and that was not enough staff. She reported it may take up to 30 minutes for staff to respond to a call light to put her on the bedpan and up to an hour to take her off once she is done. She denied any negative outcomes from the incident. b. Interview on 05/03/23 at 8:10 A.M. with Resident #25 revealed the facility does not have enough staff. She reported she had chest pain one night and needed her nitro and it took a while for the nurse to come and help her because there was another emergency on the floor and the aide was helping with that. She denied any negative outcomes from the incident. c. Interview on 05/03/23 at 8:25 A.M. with Resident #4 revealed there was a time when she was not getting her showers because they did not have enough staff. She reported the facility needs more staff. d. Interview on 05/03/23 at 8:35 A.M. with Resident #34 revealed the staff were good with incontinence care when there was enough staff. She reported sometimes she had to wait to be cleaned and sometimes it took a while to get a call light answered. She denied any negative outcome from the incident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 10 of 14 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 365578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of New Lexington 920 South Main Street New Lexington, OH 43764 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 0725 Level of Harm - Minimal harm or potential for actual harm e. Interview on 05/03/23 at 9:40 A.M. with Resident #52 revealed concerns regarding staffing levels. She reported she had to wait 30 minutes to be put on the bedpan a couple of nights ago and had to wait two and one-half hours to get off the bedpan. She denied any negative outcomes from the incident. 2. The following staff concerns were lodged during the complaint investigation related to facility staffing: Residents Affected - Many a. Interview on 05/03/23 at 5:20 A.M. with Licensed Practical Nurse (LPN) #105 revealed showers were not always done for the residents who needed two staff to assist due to staffing issues. She reported there were not enough staff on night shift. She reported day shift staffing seemed to be okay. b. Interview on 05/03/23 at 5:25 A.M. with Registered Nurse (RN) #104 reported it seemed at times there were not enough staff on night shift to provide residents with incontinence care. She reported shifts were pieced together with staff. She reported residents who needed two staff to assist with showers were not getting their showers. c. Interview on 05/03/23 at 5:32 A.M. with State Tested Nursing Assistant (STNA) #101 revealed showers were an issue for a while, but they were better now. She reported it was not that the STNAs were not doing their job, the facility was just short staffed. She reported staffing was not good. Sometimes there were not enough staff scheduled and sometimes there were call-offs. She reported night shift was short staffed a lot and there was not enough staff to schedule appropriately. She reported the facility usually ran night shift with two nurses and two aides for a census of 60 and the residents needed a lot of care. d. Interview on 05/03/23 at 5:42 A.M. with STNA #102 revealed there were residents who were not getting showers. She reported it was not that the staff did not try to give showers, there just were not enough staff. She reported there were staffing issues on midnight shift with the facility only running two STNAs and two nurses for 60 residents who required a lot of care. e. Interview on 05/03/23 at 5:51 A.M. with STNA #103 revealed she felt incontinence care was not the best because of staffing. She reported showers were not always getting done for the residents who needed two staff to assist as there was not enough staff. STNA #103 revealed she had staffing concerns regarding two nurses and two aides on night shift for 60 residents who need a lot of care. f. Interview on 05/03/23 at 7:11 A.M. with Nursing Staff Scheduler #107 revealed there should be four STNAs on night shift. She was not sure why there were only two STNAs from 11:00 P.M. to 3:00 A.M. and three from 3:00 A.M. to 7:00 A.M. She reported she was not sure how long the facility had been short staffed, but she knew it had been since she was hired and started working on 03/17/23. She reported the facility needed to fill one full-time nursing position on day shift and four full-time nursing positions on night shift and two to three full-time STNA position on night shift. She reported there were plenty of STNAs on day shift and felt it was actually overstaffed. However, none of the STNAs could be moved to night shift because they were union. g. Interview on 05/03/23 at 7:44 A.M. with RN #110 revealed incontinence care was good when they had enough staff. She reported the residents' needs of incontinence care was still met, but the staff were very busy. She reported there were staffing needs on both shifts. She reported she felt the residents' needs were met, but the staff were exhausted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 11 of 14 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 365578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of New Lexington 920 South Main Street New Lexington, OH 43764 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 0725 Level of Harm - Minimal harm or potential for actual harm h. Interview on 05/03/23 at 7:50 A.M. with LPN #106 revealed if the shower aide was not pulled to work the floor, then showers were provided, However, if a floor aide called off, the shower aide might be pulled and then showers were not completed. She reported there were issues with staffing needs in the facility. The facility had worked hard to get staff to come in and work. She reported the biggest issue was on night shift with only two aides and two nurses and 60 residents who needed a lot of care. Residents Affected - Many i. Interview on 05/03/23 at 7:58 A.M. with Housekeeping #113 revealed she felt there were not enough nursing staff in the facility. j. Interview on 05/03/23 at 9:12 A.M. with STNA #108, revealed at times when the facility was short it took longer to get to residents who need changed changed. She reported when the facility was short staffed, it was difficult to get the showers completed and the residents were the ones who suffered. She reported staffing was short at times. 3. During the onsite complaint investigation concerns were identified residents were not provided routine showers/baths. a. Review of Resident #3's medical record revealed an initial admission date of 06/30/22 with diagnoses including paraplegia, type two diabetes, acquitted absence of left leg above the knee, hemiplegia and hemiparesis following cerebral vascular disease, and essential hypertension. Review of Resident #3's plan of care, dated 07/07/22, revealed he had paraplegia related to a spinal injury. Interventions included assist with activities of daily living and locomotion as required. Encourage the resident to perform as much as possible of these activities. Review of Resident #3's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/14/23 revealed the resident was cognitively intact. The assessment indicated the resident required extensive assistance of two people for personal hygiene. The MDS indicated Resident #3 did not present with any physical, verbal , or other behavioral symptoms nor did he reject care. Review of Resident #3's shower care documentation for February 2023 revealed he received shower/bathing on 02/10/23, 02/19/23, and 02/26/23. There were no documented refusals of shower/bathing for February 2023. Review of the shower documentation for March 2023 revealed the resident received shower/bathing on 03/09/23, 03/19/23, and 03/22/23. There was one documented refusal for a shower on 03/11/23. Review of Resident #3's shower care documentation for April 2023 revealed the resident he received shower/bathing on 04/10/23. There was one documented refusal for a shower/bathing on 04/04/23. Interview on 05/03/23 at 8:45 A.M. with Resident #3 revealed he did not receive showers like he was supposed to, but stated the staff had been doing better recently. The resident reported he was not sure why he did not get his showers. On 05/04/23 at 2:05 P.M. interview with the Director of Nursing (DON) and Registered Nurse #9 revealed there was no additional documentation regarding showers for Residents #3. The DON and RN #9 verified Resident #3 had not received showers as planned during the timeframe reviewed above (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 12 of 14 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 365578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of New Lexington 920 South Main Street New Lexington, OH 43764 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many b. Review of Resident #4's medical record revealed an initial admission date of 04/10/18 and a readmission dated 04/27/19 with diagnoses including malignant neoplasm of the lower lobe of the lung, hemiplegia and hemiparesis following a cerebral infarction, and essential hypertension. Review of Resident #4's plan of care, dated 08/30/19 revealed the resident had activity of living deficits related to history of fall with left femur fracture, chronic obstructive pulmonary disease, left side hemiparesis, non-ambulatory, and lung cancer. Interventions included bath and showers per request and as needed. Skin check, shower, shampoo hair, nail care and lotion as needed. Provide weight bearing assistance up to total dependent care with bathing, dressing, and transfers. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/10/23, revealed the resident was cognitively intact. The assessment indicated she required extensive assistance of one person to physically assist with personal hygiene. The MDS indicated Resident #4 did not present with any physical, verbal , or other behavioral symptoms nor did she reject care. Review of Resident #4's progress note, dated 04/17/23 revealed the resident had the ability to bathe self, including washing, rinsing, and drying self. She was not able to wash her back or hair. She was dependent on transferring in and out of the tub/shower. Review of Resident #4's shower care documentation for February 2023 revealed the resident received showers/bathing on 02/10/23, 02/14/23, and 02/24/23. There were no documented refusals of showers for February 2023. Review of her shower documentation for March 2023 revealed the resident received showers/bathing on 03/06/23, 03/10/23 and 03/13/23. There were two documented refusals for showers on 03/09/23 and 03/28/23. Review of Resident #4's shower documentation for April 2023 revealed the resident received showers/bathing on 04/03/23, 04/05/23, 04/07/23, 04/17/23, 04/19/23, 04/26/23, and 04/28/23. There were no documented refusals of showers for April 2023. Interview on 05/03/23 at 8:25 A.M. with Resident #4 revealed there was a time when she was not getting her showers because the facility did not have enough staff and she needed two staff to assist her. She reported the facility needed more staff. Interview on 05/03/23 at 9:12 A.M. with STNA #108 revealed when the facility was short staffed, it was difficult to get the showers completed and the residents were the ones who suffer. On 05/04/23 at 2:05 P.M. interview with the Director of Nursing (DON) and Registered Nurse #9 revealed there was no additional documentation regarding showers for Residents #4. The DON and RN #9 verified Resident #4 had not received showers as planned during the timeframe reviewed above Review of a list provided by the facility revealed one resident was independent for showers, 44 residents required assistance with showers and 16 residents were dependent on staff for showers. Further review of the list revealed of the 44 residents who required assistance, 11 required two staff to assist with transfers. 4. Interview on 05/04/23 at 2:24 P.M. with the Director of Nursing (DON) revealed she was aware of concerns by residents and family about staffing. She reported there were days when it was rough, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 13 of 14 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 365578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of New Lexington 920 South Main Street New Lexington, OH 43764 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many she would be sent home during the day because she would have to come in that night to work. She reported she was needed during the day also because of issues that needed addressed but went home because she was going to work that night. Interview on 05/04/23 at 2:59 P.M. with the Administrator revealed she was aware of resident and family concerns regarding staffing. The administrator revealed the facility was working to improve the staffing in the facility. Review of facility staffing schedules and nursing assignment sheet from 04/01/23 through 05/01/23 revealed the facility did not have adequate staffing. Nursing Assignment Sheet dated 04/09/23 revealed day shift (7:00 A.M. to 7:00 P.M.) had three nurses, night shift (7:00 P.M. to 7:00 A.M.) had two nurses, day shift (7:00 A.M. to 3:00 P.M.) had four STNAs, afternoon shift (3:00 P.M. to 7:00 P.M.) had four STNAs, afternoon shift (7:00 P.M. to 11:00 P.M.) had two STNAs, night shift (11:00 P.M. to 3:00 A.M.) had three STNAs, and night shift (3:00 A.M. to 7:00 A.M.) had four STNAs. The facility census on 04/09/23 was 64 residents. Nursing Assignment Sheet dated 04/12/23 revealed day shift (7:00 A.M. to 7:00 P.M.) had four nurses, night shift (7:00 P.M. to 7:00 A.M.) had two nurses, day shift (7:00 A.M. to 3:00 P.M.) had four STNAs, afternoon shift (3:00 P.M. to 7:00 P.M.) had four STNAs, afternoon shift (7:00 P.M. to 11:00 P.M.) had two STNAs, and night shift (11:00 P.M. to 7:00 A.M.) had two STNAs. The facility census on 04/12/23 was 66 residents. Nursing Assignment Sheet dated 04/13/23 revealed day shift (7:00 A.M. to 7:00 P.M.) had three nurses, night shift (7:00 P.M. to 11:00 P.M.) had three nurses, night shift (11:00 P.M. to 7:00 A.M.) had two nurses, day shift (7:00 A.M. to 3:00 P.M.) had four STNAs, afternoon shift (3:00 P.M. to 7:00 P.M.) had four STNAs, afternoon shift (7:00 P.M. to 11:00 P.M.) had two STNAs, and night shift (7:00 P.M. to 7:00 A.M.) had two STNAs. The facility census on 04/13/23 was 67 residents. Nursing Assignment Sheet dated 04/14/23 revealed day shift (7:00 A.M. to 7:00 P.M.) had three nurses, night shift (7:00 P.M. to 10:00 P.M.) had two nurses, night shift (10:00 P.M. to 11:00 P.M.) had three nurses, night shift (11:00 P.M. to 7:00 A.M.) had two nurses, day shift (7:00 A.M. to 3:00 P.M.) had four STNAs, afternoon shift (3:00 P.M. to 7:00 P.M.) had five STNAs, afternoon shift (7:00 P.M. to 11:00 P.M.) had three STNAs, night shift (11:00 P.M. to 3:00 A.M.) had two STNAs, and night shift (3:00 A.M. to 7:00 A.M.) had three STNAs. The facility census on 04/09/23 was 65 residents. Review of facility policy titled, Nursing Department Staffing Guidelines, revised 11/2022, revealed the facility did not implement their policy regarding staffing. The policy revealed sufficient nursing staff would be scheduled on each shift to meet the needs of the residents in the facility with notification of the administrator for assistance if unable to schedule sufficient staff. A schedule may be utilized to make the schedule, fill openings or call-offs within the parameters set by the Director of Nursing. This deficiency represents non-compliance investigated under Complaint Number OH00142359. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 14 of 14