Inspection·May 17, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the Self-Reported Incidents (SRI), observation, resident interview, staff interview, and review of facility documents and policy, the facility failed to ensure allegations of resident abuse were reported to the State Survey Agency, the Ohio Department of Health (ODH.) This affected one (Resident #94) of three residents reviewed for abuse. The facility census was 148. Findings include: Review of the medical record for Resident #94 revealed an admission date of 03/01/22. Diagnoses included chronic pain syndrome, bipolar disorder, and chronic respiratory failure (CRF) with hypoxia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 was cognitively intact and required extensive assistance of one staff with activities of daily living (ADLs.) Review of the nursing progress note for Resident #94 dated 05/01/23 written by Unit Manager (UM) #236 revealed resident refused care when resident's call light was answered. The Director of Nursing (DON) and Social Worker (SW) #347 were made aware. Review of the concern form dated 05/02/23 revealed Resident #94 did not want UM #236 to answer her call light or be part of her care team. Further review of the form revealed the resident's request was granted and UM #236 would not be part of resident's care team. The form was signed by SW #347 and Resident #94. Review of the facility's SRIs for April and May 2023 revealed there were no reports filed regarding alleged emotional/verbal abuse for Resident #94. Observation and interview on 05/17/23 at 10:13 A.M. revealed Resident #94 was alert and oriented to person, time and place. Resident #94 became tearful during the interview. Resident #94 stated she was afraid of UM #236, and she thought she was a bully, that she was aggressive in her approach and that she talked to her like she was a child. Resident #94 confirmed things got worse between her and UM #236 when the nurse came into her room sometime back in April 2023 and told her that she wasn't allowed to have a catheter and that she didn't need it. Resident #94 stated she felt the nurse was disrespectful to her and she told the nurse to get out of her room and that she didn't want the nurse to ever come into her room again. Resident #94 confirmed that early in May 2023, UM #236 came into her room to answer her call light and she asked her to leave. Resident #94 confirmed UM #236 argued with her about how she had to answer the call light and the resident told UM #236 to leave and to get someone else to help her. Resident #94 reported her concerns to Licensed Practical Nurse (LPN) #356. Resident #94 confirmed she was afraid UM #236 might retaliate against her for complaining and she was upset UM #236 did not honor her request to stay out of her room. Resident #94 confirmed she could still hear UM #236 talking in the hallway, so she knew she was around, and it made her uneasy. Resident #94 confirmed SW #347 and the DON met with her and told her they would move UM #236 to another unit. Interview on 05/17/23 at 10:27 A.M. with LPN #356 confirmed early in May 2023, Resident #94 reported to her that she was afraid of UM #236, that she was a bully and she had asked UM #236 back in April 2023 to never come in her room again. LPN #356 confirmed Resident #94 was upset because UM #236 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few did not honor her request and came in her room anyway when the resident put her call light on, and UM #236 said she had to answer the light. LPN #356 confirmed she reported Resident #94's concerns to the DON. LPN #356 confirmed Resident #94 did not accuse UM #236 of verbal or emotional abuse, but calling someone a bully could be considered an allegation of possible abuse. Interview on 05/17/23 at 11:54 A.M. with the DON confirmed LPN #356 reported to her by phone on 05/01/23 that Resident #94 complained she didn't want UM #236 to be part of her care team anymore and she didn't like her personality or her customer service approach. The DON stated LPN #356 did not use the word abuse nor did she share that Resident #94 called UM #236 a bully. The DON confirmed if a resident reported a staff member was a bully, she would consider it an abuse allegation and would handle the situation per the facility's abuse protocol. The DON confirmed the facility had not initiated an abuse investigation nor had the facility reported the incident to the Ohio Department of Health (ODH). Review of the facility policy titled Abuse Prevention Program, dated March 2021, revealed the facility would ensure timely and thorough investigation of all reports and allegations of abuse. Abuse included verbal abuse-oral or written or gestured language that willfully includes disparaging and derogatory terms to residents or their families and mental abuse which included humiliation, harassment, and threats of punishment or withholding treatments or services. The facility should also ensure the reporting and filing of accurate documents relative to incidents of abuse. This deficiency represents non-compliance investigated under Complaint Number OH00142514. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 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 0610 Respond appropriately to all alleged violations. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident and staff interview, review of facility documents and review of the facility policy titled Abuse Prevention Program, the facility failed to ensure residents were protected from abuse during an investigation and failed to conduct a thorough abuse investigation. This resulted in psychosocial harm for Resident #94 after the facility failed to protect and thoroughly investigate Resident #94's allegation of emotional and verbal abuse resulting in Resident #94 being afraid to leave her room, was agitated, and tearful. This affected one (Resident #94) of three residents reviewed for abuse. The facility census was 148. Residents Affected - Few Findings include: Review of the medical record for Resident #94 revealed an admission date of 03/01/22. Diagnoses included chronic pain syndrome, bipolar disorder, and chronic respiratory failure (CRF) with hypoxia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 was cognitively intact and required extensive assistance of one staff with activities of daily living (ADLs.) Review of the nursing progress note for Resident #94 dated 05/01/23 written by Unit Manager (UM) #236 revealed resident refused care when resident's call light was answered. The Director of Nursing (DON) and Social Worker (SW) #347 were made aware. Review of the concern form dated 05/02/23 revealed Resident #94 did not want UM #236 to answer her call light or be part of her care team. Further review of the form revealed the resident's request was granted and UM #236 would not be part of resident's care team. The form was signed by SW #347 and Resident #94. Review of interview statements of residents on the unit where Resident #94 resided dated 05/02/23 revealed the residents were asked if they ever had a negative encounter with a staff member, and if they had any issues regarding the nurses' approach. All residents interviewed answered no to the questions. Observation and interview on 05/17/23 at 10:13 A.M. revealed Resident #94's door was shut upon arriving to her room. Resident #94 was alert and oriented to person, time and place. Resident #94 became tearful during the interview. Resident #94 stated she stayed in her room and kept her door shut so she would not have to interact with UM #236. Resident #94 stated she was afraid of UM #236, and she thought she was a bully, that she was aggressive in her approach and that she talked to her like she was a child. Resident #94 confirmed things got worse between her and UM #236 when the nurse came into her room sometime back in April 2023 and told her that she wasn't allowed to have a catheter and that she didn't need it. Resident #94 stated she felt the nurse was disrespectful to her and she told the nurse to get out of her room and that she didn't want the nurse to ever come into her room again. Resident #94 confirmed that early in May 2023, UM #236 came into her room to answer her call light and she asked her to leave. Resident #94 confirmed UM #236 argued with her about how she had to answer the call light and the resident told UM #236 to leave and to get someone else to help her. Resident #94 reported her concerns to Licensed Practical Nurse (LPN) #356. Resident #94 confirmed she was afraid UM #236 might retaliate against her for complaining and she was upset UM #236 did not honor her request to stay out of her room. Resident #94 confirmed she could still hear UM #236 talking in the hallway, so she knew she was around, and it made her uneasy. Resident #94 confirmed SW #347 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 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 0610 and the DON met with her and told her they would move UM #236 to another unit. Level of Harm - Actual harm Interview on 05/17/23 at 10:27 A.M. with LPN #356 confirmed early in May 2023, Resident #94 reported to her that she was afraid of UM #236, and Resident #94 called UM #236 a bully. Resident #94 had asked UM #236 back in April 2023 to never come in her room again. LPN #356 confirmed Resident #94 was upset because UM #236 did not honor her request and came in her room anyway when Resident #94 put her call light on. UM #236 said she had to answer the light. LPN #356 confirmed she reported Resident #94's concerns to the DON. LPN #356 confirmed Resident #94 did not accuse UM #236 of verbal or emotional abuse, but calling someone a bully could be considered an allegation of possible abuse. Residents Affected - Few Interview on 05/17/23 at 11:54 A.M. with the DON confirmed LPN #356 reported to her by phone on 05/01/23 that Resident #94 complained she didn't want UM #236 to be part of her care team anymore and she didn't like her personality or her customer service approach. The DON confirmed LPN #356 did not use the word abuse nor did she share that the resident called UM #236 a bully. The DON confirmed if a resident reported a staff member was a bully, she would consider it an abuse allegation and would handle the situation per the facility's abuse protocol. The DON confirmed SW #347 and the DON met with Resident #94 on 05/01/23 or 05/02/23. The DON confirmed Resident #94 told them she did not want UM #236 to enter her room again for any reason and if her call light was on, someone else should answer it. The DON stated the facility made the decision to move UM #236 to be manager of a different unit in the facility and the switch was made a week ago. The DON confirmed as the facility was coordinating the switch, UM #236 continued to work on Resident #94's unit, but LPN #229 was asked to respond to any nurse management needs for Resident #94 which involved direct interaction with the resident. The DON confirmed she had not obtained written statements from the resident and/or staff who may have had first-hand knowledge of the incident. The DON confirmed the facility had not initiated an abuse investigation and UM #236 was not suspended at any time in April or May of 2023. Interview on 05/17/23 at 1:51 P.M. with SW #347 confirmed the DON and herself interviewed Resident #94 on 05/01/23 or 05/02/23. SW #347 stated Resident #94 was agitated during the interview and said she didn't like UM #236's personality towards her and didn't feel comfortable with her providing care and didn't want the nurse to enter her room for any reason. SW #347 confirmed Resident #94 was reluctant to elaborate any further but said she felt UM #236 was gruff in her mannerisms and speech. Interview on 05/17/23 at 2:24 P.M. with UM #236 stated her relationship with Resident #94 was fine until she went into her room and told her she needed to stop refusing her diuretics and the risk this could cause to her health. UM #236 confirmed Resident #94 was unhappy with her because she got her indwelling catheter discontinued. In April 2023, Resident #94 told her she thought her approach was aggressive and she didn't want UM #236 to answer her call light, come in her room, or even speak to her. UM #236 confirmed she went to Resident #94's room sometime in May 2023 and the resident was very upset and told her to leave the room. UM #236 confirmed she told Resident #94 she was obligated to answer call lights, and Resident #94 told her to find someone else to assist. UM #236 confirmed she was not suspended at any time in April or May of 2023. Review of the facility policy titled Abuse Prevention Program, dated March 2021, revealed the facility should protect residents during abuse investigations. The facility would ensure timely and thorough investigation of all reports and allegations of abuse. Abuse included verbal abuse-oral or written or gestured language that willfully includes disparaging and derogatory terms to residents or their families and mental abuse which included humiliation, harassment, and threats of punishment or withholding treatments or services. The facility should also ensure the reporting and filing of accurate documents relative to incidents of abuse. Employees of the facility who have been accused of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 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 0610 resident abuse shall be suspended from duty immediately until the results of the investigation have been reviewed by the Administrator. Level of Harm - Actual harm This deficiency represents non-compliance investigated under Complaint Number OH00142514. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 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, observation, staff interview, and review of the facility policy, the facility failed to ensure residents who required assistance with eating received the appropriate assistance with meals/eating. This affected one (Resident #128) of three residents reviewed for meal assistance. The facility census was 148. Residents Affected - Few Findings include: Review of the medical record for Resident #128 revealed an admission date of 01/06/23. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, diabetes mellitus (DM), and aphasia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #128 was cognitively impaired and required extensive assistance of one staff with eating. Review of the physician's orders revealed an order dated 05/11/23 for Resident #128 to receive a regular diet mechanical soft texture with thin liquids. Review of the care plan for Resident #128 dated 01/07/23 revealed the resident needed assistance with activities of daily living related to impaired mobility, weakness and hemiplegia. Interventions included Resident #128 required extensive assistance of one staff with eating, and staff would provide this assistance at each meal. Observation on 05/17/23 at 9:08 A.M. revealed Resident #128 was in bed sleeping. Interview on 05/17/23 at 9:10 A.M. with State Tested Nursing Assistant (STNA) #217 confirmed Resident #128 required extensive assistance with eating. STNA #217 confirmed when she passed breakfast trays, the resident was sleepy and did not want to eat. Interview on 05/17/23 at 12:13 P.M. with STNA #217 confirmed she got Resident #128 out of bed and up in his chair at approximately 9:45 A.M. and she offered him fluids which he accepted, but she did not offer him breakfast or anything to eat. STNA #217 confirmed she did not know why she hadn't offered Resident #128 food once he woke up. Interview on 05/17/23 at 11:54 A.M. with the Director of Nursing (DON) confirmed if a resident refuses a meal or is too sleepy to eat when the meal is served, staff should hold the meal and should reapproach the resident later and offer them food. Review of the facility policy titled Meal Supervision and Assistance, dated 2022, revealed if a resident refuses to eat, staff should inform the supervisor. If a resident wishes to eat later or cannot eat when the meal is served, staff should communicate the resident's wishes to the supervisor and other staff members caring for the resident and set a more appropriate time for resident to receive the meal. This deficiency represents non-compliance investigated under Complaint Number OH00142869. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 7 of 7