Inspection·June 14, 2021

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, resident and staff interviews, and review of the housekeeping procedure manual, the facility failed to maintain residents' rooms in a clean and sanitary manner. This affected nine residents (#25, #39, #40, #60, #79, #81, #106, #136, and #141) out of 26 residents residing in the Redbud building. The facility census was 143. Findings include: Observation on 06/07/21 at 2:16 P.M., revealed Resident #106 floors not swept and mopped. Paper, Kleenex, and dirt on dark colored carpet floors. Observation on 06/08/21 at 10:39 A.M., revealed Resident #40 room had balled up tissues around her bed with noticeable crumbs and food particles on the dark carpet. Observation on 06/09/21 at 2:30 P.M., revealed Resident #141's carpet consisted of food particles scattered on the floor. Interview on 06/09/21 at 2:30 P.M., with Resident #141 reported he has not seen housekeeping in days. Observation on 06/09/21 at 2:35 P.M., revealed Resident #81 had sugar packets, napkins, and Kleenexes balled up on the floor under the bed. There were paper and crumbs scattered on the dark colored carpet. Observation on 06/09/21 at 2:40 P.M., revealed Residents (#25, #39, #60, #79, #81, #106, and #136) rooms consisted of sinks being dirty with hair in it, soap scum in the sink, fruit flies in the bathroom, toilets were stained with a brown color around the rim of the toilet, and the carpet floors had debris. Interview on 06/09/21 at 3:30 P.M., revealed Resident #39 reported her bathroom toilet needs to be cleaned and she has been asking for housekeeping all week. Resident #39 reported she does not have any soap in the soap dispenser she uses body wash to wash her hands. Resident #39 shares the bathroom with Resident #60. Interview and observation on 06/09/21 at 4:20 P.M., with Housekeeper (HK) #50 verified the condition of residents' rooms. Interview on 06/09/21 at 5:16 P.M., revealed Housekeeping Supervisor (HKS) #69 reported rooms are to be clean daily. However, HKS #69 reported she is short staff about 10 workers. The facility has increased its wages and registered with various temp services to get people to apply. HKS #69 reported the facility is in the process of bringing three more housekeepers on staff within the next two to three weeks. HKS #69 reported residents' rooms are to be cleaned minimally twice a day. Review of the manual titled Housekeeping Procedural Manual, with no date, revealed the housekeeper is responsible for the cleaning and sanitation of resident and public areas. Staff is to clean and straighten resident room daily, including restrooms and showers. Clean residents dining area, specifically-walls windows, doors, and table bases and pantry sweep and mop floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 2 of 12 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 366120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Cedar Village. 5467 Cedar Village Drive Mason, OH 45040 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 0584 This deficiency substantiates Complaint Number OH00115194, OH00114155 and OH00112495. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 3 of 12 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 366120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Cedar Village. 5467 Cedar Village Drive Mason, OH 45040 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident and staff interviews, the facility failed to provide baths/showers to residents depended on staff for care. This affected four (#34, #25, #106, and #141) of six residents sampled for activity of daily living. The facility census was 143 residents. Residents Affected - Some Findings include: 1. Review of Resident #34 medical record revealed an admission date 03/25/21, with diagnoses including muscle spasm, peripheral vertigo of left ear, phlebitis and thrombophlebitis of other deep vessels of lower extremity, weakness, urinary tract infection, spinal stenosis of cervical region, hypertension, gastro-esophageal reflux disease, pain, anemia, insomnia, anxiety disorder, depressive disorder, osteoporosis, osteoarthritis, and type two diabetes mellitus. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact with no rejection of care and required total one person assist with bathing. Review of the Activity of Daily Living (ADL) plan of care dated 04/06/2021 revealed the resident is unable to independently perform late loss activity of daily living related to decrease in mobility and disease process and requires assistance/encouragement. Review of the bath record revealed the week of 05/02-08/21 the resident received one shower on 05/04/21 and no showers the week of 05/23-29/21. Observations of Resident #34 on 06/07/21 at 3:53 P.M., revealed the resident's hair had appeared not clean, stringy, and oily. Interview with Resident #34 on 06/07/21 at 3:53 P.M., revealed the resident usually gets a shower once a week but would like a shower at least twice a week. Interview on 06/10/21 at 11:13 A.M., State Tested Nurse Aide (STNA) #115 stated she gives two baths a day and on Saturday and catch up. Most residents get baths once a week, for the residents with families that are high maintenance, they get baths twice a week. Most days only one STNA is scheduled for the unit. The nurse help when they can. 2. Review of Resident #25's medical record revealed she was admitted on [DATE]. Diagnoses included cerebrovascular disease, cognitive communication, unsteadiness on feet and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #25 to have severe cognitive impairment and dependent for all activity of daily living. Under bathing section, the MDS reports activity itself did not occur during the entire period. Interview on 06/07/21 at 2:30 P.M., with Resident #25 revealed she was not getting any showers. Reviewed of the shower sheets revealed showers days were on Tuesdays and Fridays nights. The shower sheets documented no showers were provided from January 2021 to 06/08/21. Shower sheets revealed, Resident #25 were given bed baths on 05/03/21, 05/05/21, 05/10/21, 05/12/21, 05/17/21 and 05/19/21. Reviewed nursing notes from 01/21 to 06/08/21 revealed no refusal of hygienic care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 4 of 12 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 366120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Cedar Village. 5467 Cedar Village Drive Mason, OH 45040 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 Further review of the medical record revealed no documentation of any other showers or bed baths being provide except for the six dates in May 2021. Interview on 06/08/21 at 4:09 P.M., with Registered Nurse (RN) #187 confirmed the shower sheets were accurate and there was no other evidence of bed baths or showers being provided. Residents Affected - Some 3. Review of Resident #106's medical record revealed she was admitted on [DATE]. Diagnoses included Parkinson's disease, chronic fatigue, and heart failure. Review of the quarterly MDS assessment dated [DATE], revealed Resident #106 to have intact cognition and required extensive assist of two person assist for bed mobility, toilet use, personal hygiene and total dependent for bathing. Under bathing MDS reports activity itself did not occur during the entire period. Interview on 06/07/21 at 2:15 P.M., with Resident #106 revealed she has not had a shower in months. Reviewed shower sheets revealed showers days were on Wednesdays and Sundays nights. The shower sheets documented revealed no showers were provided for the month of June 2021 nor May 2021. Resident #106 had showers documented as being provided on 04/20/21, 03/11/21, and 02/07/21 since January 2021. Further review of the medical record revealed no documentation of any other showers or bed baths being provided. Interview on 06/08/21 at 4:09 P.M., with RN #187 confirmed shower sheets were accurate and there was no other documented showers or bed baths being provided than what was listed. 4. Review of Resident #141's medical record revealed she was admitted on [DATE]. Diagnoses included quadriplegia, depressive disorder, diabetes mellitus and epilepsy. The quarterly MDS assessment dated [DATE], revealed Resident #141 had intact cognition and is total dependent of a two person assist for all activity of daily living. Under bathing MDS reports activity itself did not occur during the entire period. Review of nursing notes from 01/21 to 06/08/21 revealed no refusal of care. Reviewed shower sheets revealed showers days were on Mondays and Thursdays nights; revealed no showers held for the months from 01/21 to 06/08/21. Further review of the medical record revealed no documentation of any other showers or bed baths being provided. Interview on 06/08/21 at 4:09 P.M., with RN #187 confirmed shower sheets were accurate and there was no other documented showers or bed baths being provided. This deficiency substantiates Complaint Numbers OH00115360 and OH00114155. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 5 of 12 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 366120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Cedar Village. 5467 Cedar Village Drive Mason, OH 45040 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 Based on observation, record review and staff interviews, the facility failed to provide eyeglasses daily to a resident dependent on staff for all activities of daily living. This affected one (#25) of one resident sampled for vision. The census was 143. Residents Affected - Few Findings include: Review of medical record for Resident #25 revealed an admission date of 07/27/18 with diagnoses included cerebrovascular disease, dementia, and cognitive communication deficit. Review of quarterly minimum data set (MDS) assessment, dated 03/23/21, revealed Resident #25 was assessed being severely cognitively impaired. Resident #25 have adequate vision with glasses and is dependent for all activity of daily living. Review nursing notes revealed no concerns with refusing to wear eyeglasses. Observation on 06/07/21 at 2:32 P.M., 06/09/21 at 12:01 P.M., revealed Resident #25 was sitting in room trying to watch television. Observations on 06/14/21 at 11:50 A.M., revealed Resident #25 was not wearing eyeglasses. Interview on 06/14/21 at 11:55 A.M., with State Tested Nursing Aide (STNA) #87, the STNA assigned to Resident #25, reported she was not familiar with Resident #25 and was not sure if she wears eyeglasses. Interview on 06/14/21 at 12:00 P.M., with Licensed Practical Nurse (LPN) #120 found the glasses in resident's dresser drawer. LPN #120 reported STNAs are supposed to use the Resident Information Sheet,(RIS) to assist the residents with their needs. Resident #25's eyeglasses were placed on her face after surveyor's intervention. Resident #25 start smiling after LPN #120 placed glasses on her face. Review of Resident #25's RIS revealed Resident #25 wears glasses. Interview on 06/14/21 at 12:31 P.M., with the Director of Nursing verified Resident #25 was to wear glasses at all times when awake. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 6 of 12 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 366120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Cedar Village. 5467 Cedar Village Drive Mason, OH 45040 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, resident record reviews, and staff interviews, the facility failed to administer medications per physician orders. A total of 25 opportunities with two errors which resulted in a 8 percent medication error rate. This affected one (#114) of five residents observed during medication administration. Facility census was 143 residents. Residents Affected - Few Findings include: Observations of Medication Administration on 06/09/21 at 8:19 A.M. with Licensed Practical Nurse (LPN) #147 revealed Resident #114 was to receive Timoptic 0.5% ophthalmic solution one drop in right eye and Systane Balance (propylene glycol) 0.6 percent drops one drop in the left eye for the treatment of glaucoma to prevent a rise in intraocular pressure. LPN #147 place one drop of Timoptic 0.5% ophthalmic solution in Resident #114's left eye and started to put one drop of lantanoprost 0.005 percent drops into Resident #114's right eye when the nurse was stopped for clarification. Record review revealed Resident #114 had a physician order dated 05/11/21 for Timoptic 0.5% ophthalmic solution one drop in right eye to treat open-angle glaucoma and lantanoprost 0.005 percent drops one drop in the left eye to treat open-angle glaucoma. Interview on 06/09/21 at 8:48 A.M. with LPN #147 confirmed the drops were switched and the Timoptic 0.5% ophthalmic solution was put into the wrong eye. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 7 of 12 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 366120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Cedar Village. 5467 Cedar Village Drive Mason, OH 45040 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident record reviews, and staff interviews, the facility failed to correctly transcribe physician admission orders which resulted in residents not getting the prescribed medication. This affected one (#114) of five residents observed during medication administration. Facility census was 143 residents. Residents Affected - Few Findings include: Observations of Medication Administration on 06/09/21 at 8:19 A.M. with Licensed Practical Nurse (LPN) #147 revealed Resident #114 was to receive Timoptic 0.5% ophthalmic solution one drop in right eye and Systane Balance (propylene glycol) 0.6 percent drops one drop in the left eye for the treatment of glaucoma to prevent a rise in intraocular pressure. LPN #147 place one drop of Timoptic 0.5% ophthalmic solution in Resident #114's left eye and started to put one drop of lantanoprost 0.005 percent drops into Resident #114's right eye when the nurse was stopped for clarification. Record review revealed Resident #114 had a physician order dated 05/11/21 for Timoptic 0.5% ophthalmic solution one drop in right eye to treat open-angle glaucoma and lantanoprost 0.005 percent drops one drop in the left eye to treat open-angle glaucoma. Interview on 06/09/21 at 8:48 A.M. with LPN #147 confirmed the drops were switched and the Timoptic 0.5% ophthalmic solution was put into the wrong eye. Record review revealed Resident #114 had a physician order dated 05/11/21 for Timoptic 0.5% ophthalmic solution one drop in right eye to treat open-angle glaucoma and Systane Balance (propylene glycol) 0.6 percent drops one drop in the left eye to treat open-angle glaucoma. Interview on 06/09/21 at 8:48 A.M., with LPN #147 confirmed the drops were switched and the Timoptic 0.5% ophthalmic solution was put into the wrong eye. Interview 06/09/21 at 1:50 P.M., with Registered Nurse #129 produced the original transfer orders from the hospital that revealed a transcription error for Timoptic 0.5% ophthalmic solution one drop in both eyes daily for the treatment of glaucoma. It was transcribed as one drop in right eye when the resident returned from the hospital on [DATE]. The resident did not get the Timoptic eye drops in the left eye daily as originally ordered from 05/11/21 through 06/09/21. This could cause an increased intraocular pressure in the untreated eye. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 8 of 12 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 366120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Cedar Village. 5467 Cedar Village Drive Mason, OH 45040 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and policy reviews, the facility failed ensure to ensure medications were disposed of, if out dated and not in circulation for resident use. This had the potential to affect 143 of 143 residents who resident in the facility. The census was 143. Findings include: Observations on [DATE] at 2:13 P.M. of the [NAME] unit medication room with Registered Nurse (RN) #177 revealed an open multi-dose vial of tuberculin purified protein testing solution with the expiration date of 02/22 with no date when opened. Interview with RN #177, at the time of the observation, revealed the multi-dose vial of tuberculin purified protein testing solution should have a date when opened and was good for 28 days after opened. Observations on [DATE] at 2:45 P.M. of Peachtree unit medication room revealed an open multi-dose vial of Lidocaine 1% injectable 200 milligram (mg)/20 milliliter (ml) with no date when opened, two boxes of over the counter Simethacone 125 mg chewable tabs with an expiration date of 05/21, a tube of over the counter Antifungal Cream with an expiration date of 11/20, over the counter Delsyn Children's Cough with an expiration date of 04/20, three bottles of over the counter Stool softener 100 mg soft gels stock with an expiration date of 04/21, over the counter aspirin (ASA) 325 mg stock with an expiration date of 03/20, three bottles of over the counter ASA 325 mg with an expiration date of 02/21, over the counter ASA 325 mg with an expiration date of 04/21, two bottles of over the counter Heart Burn relief 200 mg with an expiration date of 05/20, over the counter Acetaminophen 500 mg with an expiration date of 07/20, and a tube of over the counter thick moisture Barrier Paste with an expiration date of 06/2019. Interview with Licensed Practical Nurse (LPN) #103, at the time of the observation, confirmed the open multi-dose vial of Lidocaine 1% injectable 200 mg/20 ml should have a date when opened and should be good for 30 days after opened and the expired over the counter medications. LPN #103 verified all of the medications that were discovered were expired. Observations on [DATE] at 2:20 P.M., of the Gardenia medication cart for rooms 240-269 revealed an open vial of Novalog insulin with a date when opened of [DATE] and an open vial of Novalog Insulin with no date when opened and a Humalog KwikPen with a date when opened of [DATE]. Interview on [DATE] at 2:20 P.M., with LPN #203 confirmed the open insulin was good for 28 days after opened. Review of the undated policy titled Refrigerated Medication revealed all insulin and tuberculin testing solution should be disposed of 28 days after opened. Interview on [DATE] at approximately 2:30 P.M., with the Director of Nursing revealed the pharmacy does audits on medication storage along with nursing staff to dispose of outdated medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 9 of 12 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 366120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Cedar Village. 5467 Cedar Village Drive Mason, OH 45040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, staff interviews, and review of the facility's policy, the facility failed to maintain the resident dining rooms in a clean and sanitary manner. This affected 15 residents (#14, #15, #25, #27, #39, #40, #48, #60, #79, #81, #103, #106, #110, #116, and #136) residing in the Redbud building and the potential to affect any resident that could eat in the Peach Tree dining room. The facility census was 143. Findings include: Observation on 06/07/21 at 10:51 A.M., revealed the Red [NAME] Terrace Dining Room floors had red stains on the floors, food particles scattered and spread throughout the dining room, and the base of tables were covered with dirt and crumbs. Observation on 06/09/21 at 3:15 P.M., revealed the Red [NAME] Terrace Dining Room contained dirt, debris and food crumbs on the floor. There were 11 tables with base and all of the base were covered with dirt, debris and food crumbs. Interview on 06/09/21 at 3:20 P.M., with State Tested Nursing Assistant (STNA) #150 revealed she has not seen housing keeping at all today. STNA #150 was scheduled for 7:00 A.M. to 7:00 P.M. shift. STNA #150 reported residents had used the dining room for breakfast and lunch today. Interview on 06/09/21 at 4:15 P.M., with Registered Nurse (RN) #187 denied seeing housekeeping cleaning while she was on the floor throughout the day. Interview on 06/09/21 at 4:20 P.M., with Housekeeper (HK) #50 verified the condition of the Red [NAME] Terrace Dining Room. HK #50 reported there is a shortage on housekeepers. HK #50 reported housekeeping is responsible for cleaning the dining room floors and the table bases after every meal. Interview on 06/09/21 at 4:57 P.M., with Dining Service Supervisor (DSS) #84 reported housekeeping is responsible for the cleaning the floors and the bases for each table. Dining room staff is responsible for cleaning tabletops, chairs, and equipment of each unit that have dining room services. Observation on 06/09/21 at 5:30 P.M., revealed 15 residents (#14, #15, #25, #27, #39, #40, #48, #60, #79, #81, #103, #106, #110, #116, and #136) were eating their meals in the Red [NAME] Terrace Dining Room. The dining room remained unclean. Observation on 06/07/21 at 11:20 A.M., the dining room on Peach Tree unit was noted to have a swept up pile of rubbish sitting in a corner by the kitchenette, a tablespoon's worth of dried green leafy and corn like spot on the floor under a table, an empty medicine cup, two utensil wrappers, one closed and three opened salt and pepper packets, and additional unidentifiable pieces of paper and plastic on the floor. One table had a dried sticky substance on it. Interview on 06/07/21 at 11:30 A.M., with Licensed Practical Nurse #103 verified that the dining room was not clean and prepared for lunch service. Interview on 06/09/21 at 5:16 P.M., revealed Housekeeping Supervisor (HKS) #69 reported the dining rooms are to be cleaned after meals. However, HKS #69 reported she is short staff about 10 workers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 10 of 12 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 366120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Cedar Village. 5467 Cedar Village Drive Mason, OH 45040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The facility has increased its wages and registered with various temp services to get people to apply. HKS #69 reported the facility is in the process of bringing three more housekeepers on staff within the next two to three weeks. HKS #69 reported residents' rooms are to be cleaned minimally twice a day. Review of the manual titled Housekeeping Procedural Manual, with no date, revealed the housekeeper is responsible for the cleaning and sanitation of resident and public areas. Staff is to clean and straighten resident room daily, including restrooms and showers. Clean residents dining area, specifically-walls windows, doors, and table bases and pantry sweep and mop floor. This deficiency substantiates Complaint Number OH00115194, OH00114155 and OH00112495. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 11 of 12 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 366120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Cedar Village. 5467 Cedar Village Drive Mason, OH 45040 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, the facility failed to eradicate flying insects (gnats) in resident care areas. This affected 24 residents who reside on Apple unit on the third floor and 18 residents who reside on the [NAME] unit on the second floor. The facility census 143. Residents Affected - Some Findings included: Observations on 06/08/21 at approximately 4:00 P.M., a gnat was observed and killed in the first floor board room. Observation on 06/09/21 at 8:55 A.M., a gnat was observed flying down the hall outside the [NAME] soiled utility room and confirmed by Licensed Practical Nurse (LPN) #147. Observation on 06/09/21 at 2:59 P.M., a gnat was seen on the third floor Apple unit flying near nursing station and confirmed by Registered Nurse #129. Review of the facility pest control log revealed Pest control dated 09/04/20 revealed rooms 241, 262, 263, 236 233, and 232 were treated for small flies. On 09/17/20, rooms [ROOM NUMBERS] were treated for small flies. On 09/29/20, room [ROOM NUMBER] was treated for small flies. On 05/25/21 and on 05/28/21, the Redbud Terrace unit on the second floor and the third floor rooms were treated for small flies. Interview on 06/09/21 at 3:48 P.M., with the Maintenance Director stated with eating in rooms due to COVID-19, we had gnats and had the pest control treated every Tuesday to treat the drains. The gnats have been noticed at the end of when it was getting cold maybe February, there was one here and there. The pest control specialist started coming out in March. This deficiency substantiates Complaint Number OH00115194 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 12 of 12