Inspection·February 26, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Interview on 02/21/24 at 11:45 P.M. with the director of nursing (DON) confirmed the lack of showers provided to Resident #22. This deficiency represents non-compliance investigated under Complaint Number OH00150757. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 2 of 16 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 02/26/2024 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 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Let each resident or the resident's legal representative access or purchase copies of all the resident's records. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide access to medical records. This affected one resident (#82) of one residents reviewed for medical records. The facility census was 59. Findings included: Record review revealed Resident #82 was admitted to the facility on [DATE] with diagnoses including dementia without behaviors, orthostatic hypotension, non-st elevation myocardial infarction, bipolar disorder, congestive heart failure, major depression, anemia, hypertension, and cardiomegaly. Review of a minimum data set completed on 11/17/23 revealed Resident #82's cognition did not remain intact, did not have behaviors, she used a walker and a wheelchair, required maximum assistance for toileting hygiene, maximum assistance for toilet transfers, moderate assistance to walk 10 feet, was dependent for wheelchair use, and was occasionally incontinent. Resident #82 had a durable power of attorney (DPOA). Review of the medical record did not contain any evidence the facility processed a request for medical records to be received by Resident #82's DPOA. Interview on 02/21/24 at 12:01 P.M. with Anonymous Source (AS) #268 revealed a request for medical records had been filed but was never completed. Interview on 02/23/24 at 11:19 A.M. via telephone with Admissions Concierge (AC) #117 revealed Resident #82's responsible party had requested medical records, filled out the request form, and the records were ready within two days for the family to pick up. AC #117 stated once she had the records ready for the family, she left them with a nurse at the nurses station. Interview on 02/26/24 at 9:26 A.M. with Regional Support Administrator revealed the facility did not have any evidence of the records request or evidence the records were provided to Resident #82's family. During the course of the survey, the surveyor requested to review a copy of the facility policy for obtaining a copy of a resident medical record. On 02/26/24 at 2:31 P.M. interview with the director of nursing (DON) confirmed there was no policy for medical records request procedure. This deficiency represents non-compliance investigated under Complaint Number OH00151293. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 3 of 16 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 02/26/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain accurate care plans to reflect current mobility status. This affected one resident (#82) of four residents reviewed for falls. The facility census was 59. Findings included: Record review revealed Resident #82 was admitted to the facility on [DATE] with diagnoses including dementia without behaviors, orthostatic hypotension, non-st elevation myocardial infarction, bipolar disorder, congestive heart failure, major depression, anemia, hypertension, and cardiomegaly. Review of a minimum data set completed on 11/17/23 revealed Resident #82's cognition did not remain intact, did not have behaviors, she used a walker and a wheelchair, required maximum assistance for toileting hygiene, maximum assistance for toilet transfers, moderate assistance to walk 10 feet, was dependent for wheelchair use, and was occasionally incontinent. Review of a hospice note dated 01/29/24 revealed Resident #82 was no longer able to walk, unable to stand and pivot independently, and was a one to two person assist for transfers due to increased weakness. Review of a care plan and [NAME] completed on 01/05/22 revealed Resident #82 was ambulatory in her room and throughout the facility using a walker and supervision was provided from staff. Interview on 02/23/24 at 12:01 P.M. with Anonymous Source (AS) #268 revealed Resident #82 was non-ambulatory. Interview on 02/23/24 at 1:19 P.M. with State Tested Nursing Assistant (STNA) #150 revealed Resident #82 had not been able to walk by herself for months. Interview on 02/23/24 at 2:45 P.M. with AS #242 revealed Resident #82 was not able to stand on her own. Interview on 02/23/24 at 3:07 P.M. with the Director of Nursing (DON) confirmed Resident #82's care plan and [NAME] were not updated to reflect Resident #82's most recent abilities. Review of a policy titled Care Plan Policy dated 04/2018 revealed the MDS Nurse will have overall responsibility to assure each resident has a personalized and individual care plan and it is reviewed and updated routinely and as needed, the care plan will be updated as needed with changes within seven business days of the time the change is identified or ordered, items needed by the direct care staff to provide care may be placed in PointClickCare. The comprehensive care plan should contain summaries of the resident's needs, strengths, and goals, and resident history that is relevant to status, needs, and goals. This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number OH00151327. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 4 of 16 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 02/26/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to communicate a speech therapy recommendation to the physician thereby delaying a diagnostic test. This affected one resident (#34) of five residents reviewed for quality of care. The facility census was 59. Residents Affected - Few Findings included: Record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including pulmonary embolism, altered mental status, unspecified dementia, and hypertension. Review of a minimum data set (MDS) completed on 12/07/23 revealed Resident #34 had no signs of a swallowing disorder, had a five percent or greater weight loss in one month or ten percent or greater weight loss in the last six months without being on a prescribed weight-loss regimen, and was receiving a mechanically altered diet. Review of a care plan updated on 02/02/24 revealed Resident #34 had a potential from nutritional problem related to advanced age, dementia, morbid obesity, mechanically altered diet, moisture associated skin damage, varied intakes, supplement, presence of edema, diuretics, and a significant weight loss with an intervention for speech therapy to examine for swallowing evaluation as ordered by the physician. Review of orders revealed Resident #34 had an order in place for a regular diet with pureed texture and thin liquid consistency dated 09/18/23, an order for house supplement eight ounces dated 02/09/24, Review of a therapy note dated 01/21/24 at 11:24 A.M. revealed a State Tested Nursing Assistant (STNA) came to the therapy department due to Resident #34 requesting a regular diet and after explaining to Resident #34 she had an order for an altered diet, resident refused to eat. Resident #34 was noted to have weight loss and it was recommended that speech therapy evaluate and treat Resident #34 to determine if she was appropriate for a diet upgrade. Review of a speech therapy evaluation from 01/22/24 signed at 6:53 P.M. by Speech Therapist (ST) #101 revealed a swallow study had been requested to rule out blockage, webbing and risk of aspiration related to esophageal discomfort and safe swallowing. Review of a weight-change note from 02/02/24 at 1:53 P.M. revealed Resident #34 had a significant weight loss of 26 percent and the dietician noted it was likely due to resident refusing to eat due to dislike of her current diet texture. Speech therapy would assess for a diet upgrade. There was an order for a modified barium swallow study to rule out aspiration and determine upgrade readiness oral-pharyngeal dated 02/05/24. Review of a weight-change note from 02/09/24 at 1:25 P.M. revealed Resident #34 had a weight gain of 7.9 percent and there was an order for modified barium swallow to determine if Resident #34's diet texture could be upgraded due to dislike of current pureed texture. Review of meal intakes from 01/16/24 through 02/14/24 revealed Resident #34 had variable intakes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 5 of 16 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 02/26/2024 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 from zero to 100 percent. Level of Harm - Minimal harm or potential for actual harm Interview on 02/14/24 at 10:45 A.M. with Licensed Practical Nurse (LPN) #113 revealed nursing staff had been requesting a barium swallow for Resident #34 for three weeks and it had not been scheduled yet due to transportation. LPN #113 stated the delay for the barium swallow was due to the physician signing the order, then the order and information goes to the Assistant Director of Nursing, then the hospital receives the information and schedules an appointment which can take a couple of weeks. LPN #113 stated she was unsure if a referral was ever sent for the modified barium swallow. LPN #113 stated Resident #34 does not like to eat pureed food and has had weight loss due to refusal to eat. Residents Affected - Few Interview on 02/14/24 at 3:11 P.M. with Assistant Director of Nursing (ADON) revealed a modified barium swallow was ordered for Resident #34 on 02/06/24 then the facility had to wait for the physician to sign the order which was completed on 02/13/24. ADON stated once the order was signed, information was faxed to the hospital and then handed off to transportation to schedule the appointment. Interview on 02/14/24 at 3:48 P.M. with Driver #122 revealed the referral for Resident #34's modified barium swallow was resent today (02/14/24) at 12:14 P.M. due to a fax confirmation not printing out when previously sent. Driver #122 revealed an appointment was scheduled for 03/11/24 which was the earliest appointment available and was not related to transportation issues. Interview of 02/15/24 at 12:15 P.M. with the Director of Nursing (DON) and Regional Support Administrator confirmed there was not a process in place for therapy to notify nursing staff of new recommendations. Interview on 02/15/24 at 12:28 P.M. with Physician #140 revealed he was unsure of what date speech therapy made the recommendation for Resident #34 to receive a modified barium swallow, but he is typically notified by phone, fax, or when he is in the facility. During the course of the survey, the surveyor requested a policy for therapy recommendations but a policy was not provided. This deficiency represents non-compliance investigated under Complaint Number OH00150757. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 6 of 16 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 02/26/2024 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to replace Resident #62's broken glasses. This affected one resident (#62) of four residents reviewed for accidents. The facility census was 59. Residents Affected - Few Findings included: Record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, osteoarthritis, dry eye syndrome of unspecified lacrimal gland, hyperlipidemia, chronic pain syndrome, scoliosis, repeated falls, mild cognitive impairment, anxiety, and major depression. Care plan review revealed Resident #34 was at risk for falls related to multiple sclerosis, chronic pain, psychiatric medication use, pain medication use, and incontinence of bladder. Interventions included placing glasses within reach and encourage use. Review of a preliminary list for a vision clinic for 03/19/24 revealed Resident #62 was not on the list for the upcoming eye doctor appointment. Observation on 02/13/24 at 1:57 P.M. of Resident #62 revealed the resident was seated in a wheelchair next to her bed and was not wearing glasses. Interview on 02/14/24 at 9:33 A.M. with Family Member (FM) #216 revealed during a fall on 02/02/24, Resident #62's glasses were ruined beyond repair and Resident #62 had not been seen by an eye doctor since January 2023. Observations on 02/14/24 at 9:47 A.M. and 3:10 P.M. revealed Resident #62 not wearing glasses. Observation on 02/15/24 at 1:03 P.M. revealed Resident #62 was seated in her room and not wearing glasses. Interview on 02/15/24 at 1:13 P.M. with the Director of Nursing (DON) revealed Resident #62 was not on the list for the eye doctor and her family did not sign up for the program. The DON was unable to provide documented evidence of declination of ancillary services and stated, they did not decline, they just did not sign a consent. Interview on 02/15/24 at 2:10 P.M. with the DON revealed she had met with Resident #62's family regarding glasses and getting a new appointment but the eye doctor was just at the facility on 01/23/24. The DON stated family requested Resident #62 receive a new prescription for glasses, so she began to reach out to the vision clinic which previously provided services for the facility not realizing the facility switched providers. The DON stated once she was aware of the new vision clinic provider on 02/14/24, she sent information to the new eye doctor but Resident #62 did not have a consent in place for services. The DON stated encouraging Resident #62 to wear her glasses being included in Resident #62's fall care plan was a generic care plan that everyone has. Review of a policy titled Resident Healthcare Appointments/Ancillary Services (dated 02/2022) revealed upon admission or shortly thereafter ancillary services such as optometry, podiatry, dental, audiology, and mental health services will be offered, and consent accepted or declined. Periodically (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 7 of 16 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 02/26/2024 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 0685 Level of Harm - Minimal harm or potential for actual harm through their stay, the residents will be asked if they give consent to ancillary services. Typically, the Social Service department will manage ancillary services assisted by the nursing department. There are times when residents verbally inform the center staff of the need for scheduled appointment, and in such cases the center will contact the physician office and verify the need for the appointment and proceed to scheduling the appointment. The family/resident will be informed of the appointment. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00150942. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 8 of 16 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 02/26/2024 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to provide adequate supervision to prevent residents from falling. This affected two residents (#62, #82) of three residents reviewed for accidents. The facility census was 59. Actual Harm occurred on 02/02/24 when Resident #62 was being prepared for a transfer from her wheelchair to her bed by one staff member who then left her alone unsupervised. Resident #62 fell from her wheelchair and sustained a fracture to her right wrist. Actual Harm occurred on 02/10/24 when Resident #82, who required a dependent assist from staff for transfers, fell in the bathroom when left unsupervised and sustained a right hip fracture resulting in hospitalization. Findings included: 1. Record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, stiffness of left elbow, chronic pain syndrome, hyperlipidemia, scoliosis, osteoarthritis, and mild cognitive impairment. Review of a minimum data set (MDS) assessment completed on 11/14/23 revealed Resident #62 had a brief interview for mental status of two (severe cognitive impairment), had impairments to bilateral upper and lower extremities, used a wheelchair, and required a dependent assist of two staff for chair to bed transfers. Review of orders revealed Resident #62 had an order starting on 10/22/23 for a full body lift for all transfers (mechanical hoyer transfer). Review of a care plan with a review date of 02/07/23 revealed Resident #62 was at risk for falls related to multiple sclerosis, chronic pain, pain and psychotropic medication use, and incontinence of bladder with a goal to remain injury free through the next review date. Fall interventions included call light within reach, non-skid footwear, attending activities, grab bars as enablers, have commonly used items within easy reach, perimeter mattress to bed, place glasses within reach and encourage use, provide assistance as needed for mobility tasks and assure utilization of appropriate devices, and to ensure wheelchair brakes are fully engaged prior to transferring resident to her chair. Review of a nursing note from 02/02/24 at 11:50 A.M. by Licensed Practical Nurse (LPN) #170 revealed Resident #62 returned to the facility from the hospital with a splint to right limb due to a broken wrist. Review of a nursing note from 02/02/24 at 8:00 P.M. by LPN #170 revealed Resident #62 was sent out via ambulance to the emergency department due to possible right wrist fracture from a previous fall. All responsible parties were made aware. Review of a fall investigation from 02/02/24 revealed the nurse was called to Resident #62's room and found resident lying on the floor in front of her bed with no injuries noted at this time, and the immediate action taken was to get help from the other side of the facility to pick resident up (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 9 of 16 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 02/26/2024 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 0689 Level of Harm - Actual harm with the hoyer lift and put her in bed. Other information obtained for the investigation revealed Resident #62 was leaning in her chair and a State Tested Nursing Assistant (STNA) (later identified as STNA #145) was attempting to move resident from her chair to the bed when Resident #62 leaned and came out of the chair and onto the floor. Residents Affected - Few Review of a statement from 02/02/24 by STNA #175 revealed while in another resident's room, STNA #145 informed her Resident #62 had fallen out of her chair and she needed help. Additional STNAs were walking by and stated they would help as well. STNA #175 stated when she entered the room, Resident #62 was face down on the floor at the bottom of the bed with her head facing the window and her feet pointed towards the door of her room. Review of a statement from 02/02/24 by STNA #110 revealed she was coming from the kitchen when she saw STNA #145 and STNA #175 coming from the top of hallway one. STNA #110 overheard other STNAs say someone was on the ground and she volunteered to help get the resident up. When STNA #110 entered Resident #62's room, resident was lying face down at the foot of the bed on the floor with her feet and legs towards the door and her face was laying on the wheels of the bed. STNA #110 stated a pillow had been placed under Resident #62's head. Resident #62 had a bruise to her forehead. Review of a statement from 02/02/24 by STNA #190 revealed she was taking trays to the kitchen when she saw aides coming down the hall. When she heard a resident was on the floor, she offered to help. Upon entering the room, Resident #62 was face down with her head on the bottom bed lock and her feet were facing the door. Review of a statement from 02/02/24 by STNA #145 revealed she was in Resident #62's room to return her to bed and Resident #62's face was down on her bedside table. STNA #145 moved the tray table and Resident #62 started to lean forward in the chair grabbing her ankle. STNA #145 stated she told Resident #62 she was going to fall and stop, while attempting to hold one of Resident #62's shoulders back and using the other hand to try to tilt the wheelchair back but the chair would not tilt back. STNA #145 stated when she turned to open the door for help, because no one came to assist when she had turned the call light on, she heard Resident #62 fall to the floor. Review of X-ray collected on 02/02/24 at 9:36 P.M. revealed Resident #62 had a minimally displaced mild impaction fracture of the distal ulnar metadiaphysis. There was apex dorsal angulation. Interview on 02/13/24 at 1:28 P.M. with the Director of Nursing (DON) revealed STNA #145 was adjusting the resident in her chair, not necessarily transferring her. The DON revealed the incident report was filled out by a nurse who wasn't even there. Interview on 02/13/24 at 1:33 P.M. with STNA #145 revealed Resident #62 was leaning forward in her chair and grabbing her ankles with her good (right) hand. STNA #145 stated she thought Resident #62 was going to fall, so she turned on the call light for assistance. STNA #145 stated she tried to hold the resident up by her shoulder, with one hand, while using the other hand to attempt to tilt her wheelchair back, but it would not tilt and no one came to answer the call light. STNA #145 stated Resident #62 was too close to the edge of her seat. STNA #145 stated she went to go get help and as she was walking towards the door, she heard Resident #62 fall. STNA #145 stated Resident #62 was not immediately sent out for a checkup because the nurse determined she did not need to go to the hospital. Observation on 02/13/24 at 1:57 P.M. revealed Resident #62 was seated in her bed with a light (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 10 of 16 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 02/26/2024 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 0689 yellow, fading bruise to her left eye, a cast to her right arm, no glasses, and dry lips. A tilting wheelchair was noted at bedside, a perimeter mattress was in place, and a soft touch call light was in reach. Level of Harm - Actual harm Residents Affected - Few Interview on 02/14/24 at 9:33 A.M. with Family Member (FM) #216 revealed Resident #62 had told her and an STNA that she was dropped. Interview on 02/14/24 at 9:47 A.M. with Resident #62 revealed the girls were trying to move her when she was dropped. Resident #62 did have a hard time communicating but was able to answer yes or no questions regarding the incident. Interview on 02/14/24 at 10:30 A.M. with STNA #133 revealed when she asked Resident #62 what happened to her wrist and face, Resident #62 told STNA #133 she was dropped by STNA #145. STNA #133 stated she reported this to an LPN (#139) but did not write a statement due to leaving work for an emergency. Interview on 02/14/24 at 3:34 P.M. with Registered Nurse (RN) #155 revealed she was down the hall from Resident #62's room when STNA #145 went in to take care of Resident #62. RN #155 stated she believed the call light came on but there were multiple lights on, so it was difficult to tell. RN #155 stated STNA #145 was going in to transfer Resident #62 and would usually prepare the resident for a transfer, then come to the doorway to call for help when the resident was ready. When RN #155 entered the room, the hoyer lift was not near Resident #62 and the left side of Resident #62's face was on the floor and her left arm was under her. RN #155 stated she assessed Resident #62 and did not notice any injuries. Observation on 02/15/24 at 02/15/24 revealed Resident #62 resting in bed, perimeter mattress in place. Interview on 02/15/24 at 2:03 P.M. with Regional Support Administrator confirmed Resident #62 fell and sustained a fractured wrist due to being left unsupervised in a compromising position. 2. Closed record review revealed Resident #82 was admitted to the facility on [DATE] with diagnoses including dementia without behaviors, orthostatic hypotension, non-ST elevation myocardial infarction, bipolar disorder, congestive heart failure, major depression, anemia, hypertension, and cardiomegaly. Review of a minimum data set (MDS) assessment completed on 11/17/23 revealed Resident #82's cognition did not remain intact, did not have behaviors, she used a walker and a wheelchair, required maximum assistance for toileting hygiene, maximum assistance for toilet transfers, moderate assistance to walk 10 feet, was dependent for wheelchair use, and was occasionally incontinent. Review of a care plan from 11/29/23 revealed Resident #82 was at risk for falls related to dementia, poor safety awareness, psychoactive medications, forgetting to use walker, periods of agitation, and history of falls with a goal of remaining free from injury through next review date. Interventions included administer medications as ordered, be sure call light is within reach, educate resident and family about safety reminders and what to do if a fall occurs, ensure the resident is wearing appropriate footwear when ambulating/in wheelchair, non-skid footwear, follow fall protocol. Review of the care plan for activities of daily living revealed no instructions for the level of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 11 of 16 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 02/26/2024 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 0689 assistance Resident #82 required for transfers. Level of Harm - Actual harm Review of Point of Care (POC) documentation from 01/23/24 to 02/12/24 for walking in room, transfer and toilet use revealed no documentation. Review of POC documentation from 01/23/24 to 02/12/24 for urinary continence revealed Resident #82 was intermittently incontinent. Review of POC documentation from 01/23/24 to 02/12/24 for sitting in bed revealed Resident #82's ability fluctuated from independent to maximum assistance. Review of POC documentation from 01/23/24 to 02/12/24 for lying down to sitting on the side of the bed revealed Resident #82's ability fluctuated between minimum to maximum assistance. Review of POC documentation from 01/23/24 to 02/12/24 for sit to stand revealed Resident #82 required moderate to maximum assistance. Review of POC documentation from 02/13/24 to 02/12/24 for toilet transfers revealed Resident #82 required minimum to maximum assistance. Review of POC responses from 01/23/24 to 02/12/24 for walking 10 feet revealed Resident #82 required minimum assistance. Residents Affected - Few Review of Hospice documentation from 01/22/24 revealed Resident #82 was no longer able to walk, unable to stand and pivot transfer independently, required a one to two person assist for transfers at all times due to increased weakness, would often yell I'm going to fall while being transferred, and was unable to scoot herself up in the bed anymore and became very short of breath when she tried. Review of a Fall Risk Assessment completed on 01/23/24 revealed Resident #82 was unable to independently come to a standing position and exhibited loss of balance while standing. Resident #82's fall risk score was 19, indicating the resident was at a high risk for falls. Review of a [NAME] revealed no direction to staff of Resident #82's needs for transferring. Review of a nursing note from 02/10/24 at 7:19 P.M. by LPN #165 revealed the nurse was called to Resident #82's room, wheelchair was noted in the bathroom doorway, and resident was sitting on her buttocks, legs straight out in front of her, facing the toilet with her hands at her sides, holding her up. Resident #82 stated I unlocked my wheelchair so I could get in it but it moved and I fell. LPN #165 assessed the resident for injuries and found slight redness to her upper back, and determined range of motion was within normal limits. All responsible parties were notified. Review of a nursing note from 02/10/24 at 8:16 P.M. by LPN #165 revealed the nurse offered to send Resident #82 to the hospital for evaluation due to complaint of right thigh pain and family declined. Review of a nursing note from 02/10/24 at 9:15 P.M. by RN #195 revealed Resident #82 was sent to the hospital via ambulance per family request due to increased pain in her right lower extremity after a fall. Resident #82 was admitted to the hospital for a right greater trochanter break. Review of a Head-to-Toe Assessment completed on 02/10/24 at 7:11 P.M. revealed Resident #82 had slight redness to her upper back. Review of a fall investigation from 02/10/24 revealed no injuries were noted to Resident #82 after she fell, then listed injury as right thigh with a pain of five. The mobility section of the investigation revealed Resident #82 was wheelchair bound. Review of a statement from 02/10/24 by STNA #105 revealed she was in the dining room when she heard Resident #82 yell for help, and she ran to her room. STNA #105 reported this to a nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 12 of 16 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 02/26/2024 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 0689 Review of additional statement from STNA #105 dated 02/10/24 revealed STNA #105 was the only staff member on the unit at the time of the fall. Level of Harm - Actual harm Residents Affected - Few Interview on 02/21/24 at 11:25 P.M. with the DON revealed Resident #82 was able to walk and transfer by herself but staff should provide total assistance for safety reasons. Interview on 02/21/24 at 12:01 P.M. with Anonymous Source (AS) #268 revealed Resident #82 had approximately 11 to 12 falls within the last year with multiple injuries including a broken arm and hot coffee scalding her. AS #268 stated Resident #82 was a high fall risk and was told she was left unattended in the bathroom (from the fall on 02/10/24). AS #268 stated Resident #82 was screaming in pain and screaming she wanted to die. AS #268 stated Resident #82's hip was broken in four places and required the placement of a rod. AS #268 stated she did not decline to have Resident #82 sent to the hospital at any time and begged the staff to send her to the hospital. AS #268 stated Resident #82 was dependent on staff to transfer her from her chair to the toilet, and Resident #82 was still wearing a sling on her broken arm. Resident #82 was non-ambulatory. AS #268 stated after the fall, Resident #82's right foot was rotated and laying on its side. Interview on 02/21/24 at 1:15 P.M. with STNA #145 revealed Resident #82 required a one-person minimum assist for transfers. The STNA stated staff know how much assistance to provide to residents based on their [NAME]. Interview on 02/21/24 at 1:19 P.M. with STNA #150 revealed Resident #82's ability to transfer fluctuated; sometimes she was a minimum assist and other times staff had to use some muscles. STNA #150 reported Resident #82 had been non-ambulatory for a while. Interview on 02/21/24 at 1:29 P.M. with LPN #165 revealed she was called to the memory care unit and saw Resident #82 on the floor in the bathroom with her legs facing the toilet and her back towards the sink. LPN #165 stated Resident #82 was non-ambulatory but was able to transfer herself. LPN #165 stated Resident #82 had no injuries at the time, but later began to complain of pain. Multiple attempts were made to interview STNA #105 and were unsuccessful. The follow up interview on 02/21/24 at 3:07 P.M. with the DON confirmed Resident #82's care plan was not up to date and the [NAME] did not list the level of assist Resident #82 required for mobility. The DON also confirmed hospice documentation stated Resident #82 was dependent on staff for transfers and therefore would not have been able to wheel herself into the bathroom and transfer herself independently onto the toilet. This deficiency represents non-compliance investigated under Complaint Number OH00151293, Complaint Number OH00150942, Complaint Number OH00150797. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 13 of 16 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 02/26/2024 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to provide adequate hydration to a resident, who depended on staff for assistance with drinking fluids, to meet the resident's hydration needs. This affected one resident (#62) of one resident reviewed for dehydration. The facility census was 59. Residents Affected - Few Actual Harm occurred to Resident #62 on [DATE] when the facility failed to provide the resident with adequate fluid intake and the resident was admitted to the hospital for treatment of acute kidney injury and dehydration. Findings included: Record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, stiffness of left elbow, chronic pain syndrome, hyperlipidemia, scoliosis, osteoarthritis, and mild cognitive impairment. Review of a minimum data set (MDS) assessment completed on [DATE] revealed Resident #62 had a brief interview for mental status score of two (severe cognitive impairment), had no behaviors, had impairment to bilateral upper extremities, required dependent assistance of two staff members for activities of daily living, set-up help for meals, and was always incontinent of bowel and bladder. Review of orders revealed Resident #62 had an order on [DATE] for a regular diet with pureed texture and thin liquids and for dietician to evaluate for optimal nutritional values. Review of an annual Nutrition Assessment completed on [DATE] revealed Resident #62's estimated daily nutritional needs included 1,894 to 2,152 milliliters (ml) of fluids, to monitor intakes and elimination. Review of a quarterly Nutrition Assessment completed on [DATE] revealed Resident #62 had adequate hydration. Review of a care plan from [DATE] revealed Resident #62 had dehydration or potential fluid deficit related to diuretic use with a goal of remaining free of symptoms of dehydration and maintain moist mucus membranes, good skin turgor, and interventions including monitor and report decreased/no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset of confusion, increased pulse, headache, fatigue/weakness, fever, thirst, and dry/sunken eyes. An activities of daily living care plan revealed Resident #62 should be provided set-up help and a dietary care plan to offer/encourage fluids of choice. Review of Point of Care (POC) response for frequent check and change for Resident #62, with a timeframe of [DATE] through [DATE], revealed no documentation indicating check and changes were completed. Review of POC response for urinary incontinence revealed Resident #62 was incontinent twice on [DATE], once on [DATE], no documentation for [DATE], twice on [DATE], twice on [DATE], three times on [DATE], twice on [DATE], once on [DATE] then was out of the facility from [DATE] through [DATE], was incontinent once on [DATE], twice on [DATE], and once on [DATE]. Review of POC response for fluid intakes revealed Resident #62 consumed 600 ml on [DATE], 1,080 ml on [DATE], 1,200 ml on [DATE], 720 ml on [DATE], 360 ml on [DATE], 960 ml on [DATE], 360 ml on [DATE], 480 ml on [DATE], 360 ml on [DATE], 960 ml on [DATE], 1,080 ml on [DATE], 960 ml on [DATE], 480 ml on [DATE], 720 ml on [DATE], 720 ml on [DATE], 840 ml on [DATE], 960 ml on [DATE], was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 14 of 16 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 02/26/2024 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 0692 available on [DATE], 960 ml on [DATE], 1,080 ml on [DATE], 480 ml on [DATE], 760 ml on [DATE], 720 ml on [DATE], was out of the facility from [DATE] through [DATE], and had 480 ml on [DATE]. Level of Harm - Actual harm Residents Affected - Few Resident #62's fluid intake was significantly below her daily needs of 1894 ml to 2152 ml as indicated on her nutritional assessment completed [DATE]. Review of a therapy note from [DATE] at 8:48 A.M. by Director of Rehab (DOR) #119 revealed Resident #62 was screened for therapy services due to having a right wrist fracture from a fall on [DATE]. The resident was not able to use her right arm and hand due to the fracture. Review of a general note on [DATE] at 2:55 P.M. by Registered Nurse (RN) #155 revealed Resident #62's right arm was wrapped with splint and wrap, medicated as needed for pain and discomfort, and is a feed and must be offered liquids frequently. Review of a therapy note from [DATE] at 9:37 A.M. by Certified Occupational Therapy Assistant (COTA) #160 revealed Resident #62 is unable to use left upper extremity and with recent fracture, is unable to use right upper extremity and is a total feed due to this. Review of nursing note from [DATE] at 6:15 P.M. by RN #155 revealed Resident #62 had a moist cough with mucus, family was at bedside and requested resident to be sent to the emergency department for evaluation. Physician and Assistant Director of Nursing notified. Review of nursing note from [DATE] at 11:08 P.M. by Licensed Practical Nurse (LPN) #170 revealed Resident #62 was admitted to the hospital for acute kidney injury and dehydration. Review of labs from [DATE] revealed Resident #62 tested positive for a urinary tract infection with Klebsiella pneumoniae. The resident's sodium level was high with a level of 153.3 mmol/L (normal 136-146), blood urea nitrogen (BUN was high at 40 mg/dL (normal 8-26), creatine was high at 1.29 mg/dL (normal 0.52-1.04), and a chronic kidney disease epidemiology collaboration score of 41.5 (normal above or = 60 mL/min) indicating moderate to severe decrease in function. Review of an After Visit Summary (from the hospital) from [DATE] revealed Resident #62 should discontinue torsemide (a diuretic medication) 100mg tablet and torsemide 20mg tablet. Observation on [DATE] at 1:57 P.M. of Resident #62 revealed the resident sitting next to her bed in her wheelchair, her lips were dry and pale. A State Tested Nursing Assistant (STNA) was walking by, the surveyor requested assistance for Resident #62 to receive a drink of water. Resident #62 took two long swigs of the water. Interview on [DATE] at 9:33 A.M. with Family Member (FM) #216 revealed Resident #62 is not able to use her hands. Family Member #216 revealed when the resident was admitted to the hospital with dehydration she was severely ill, almost died and required IV hydration. Observation on [DATE] at 3:10 P.M. and [DATE] at 1:03 P.M. revealed Resident #62 had dry and pale lips. Interview on [DATE] at 3:34 P.M. with RN #155 revealed acute kidney injuries can be caused by not having enough to drink but could have also been caused by multiple sclerosis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 15 of 16 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 02/26/2024 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 0692 Level of Harm - Actual harm Residents Affected - Few Interview on [DATE] at 1:03 P.M. with Resident #62 revealed resident's mouth was dry, her lips were dry and peeling. When asked if staff are offering fluids, Resident #62 stated no and when asked if she would like surveyor to have a staff member come help her get a drink, Resident #62 stated yes. Interview on [DATE] at 12:36 P.M. with Dietitian #100 revealed that when she documented on the quarterly nutritional assessment dated [DATE] adequate hydration she based it off of staff reports and things like that. Dietitian #100 stated Resident #62's annual review dated [DATE] unfortunately was not done by her. Dietitian #100 stated it's all very general. The fluid recommendations are vague, and it depends. Interview on [DATE] at 2:03 P.M. with Regional Support Administrator confirmed documentation in the POC, care plan, and notes regarding Resident #62's hydration status. Review of a policy titled Hydration Policy dated 04/2018 revealed each resident shall be provided with sufficient fluids to maintain acceptable parameters of electrolyte balance and should be considered upon admission, significant change, annually and at a minimum quarterly by the Dietary Professional. Additionally, fluids based on resident preferences should be provided at each meal. This deficiency represents non-compliance investigated under Complaint Number OH00150757. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365578 If continuation sheet Page 16 of 16