Inspection·April 3, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observation and interview, the facility failed ensure resident equipment was in good repair and failed to keep the dining room clean. This affected six (Residents #29, #62, #67, #94 #107, and #121) residents. The facility census was 136. Findings include: 1. During an observation on 03/26/24 at 1:01 P.M. the arm rests and seat on the over the toilet chair in Resident # 29's were torn in several places. Some of the tears were covered with tape. The chair arms had several ripped and torn areas that were not covered, and the taped areas had rough edges on them. During an interview at the time of the observation, State Tested Nursing Assistant (STNA) #18 confirmed the above findings. 2. During an observation on 03/25/24 at 11:28 A.M., Resident #62's mattress was too small for the bed. There was a two foot gap between he top of the bed frame and the mattress at the head of the bed. Resident #62 stated at the time of the observation he has asked for a new mattress on several occasions and each time is told it is on order. During interview on 03/26/24 at 12:24 P.M. with Licensed Practical Nurse (LPN) #180 confirmed the mattress was too small for the bed. 3. During observation on 03/26/24 at 12:56 P.M., Resident #121's wheelchair had white tape on the arm of her wheelchair, to cover a tear. Resident #121 stated at the time of the observation, the arm of her wheelchair is ripped and taped over. Resident #121 held onto the arm and shook it and stated it was not very secure. During interview on 03/26/24 at 12:56 P.M., STNA #18 confirmed the above findings. Review of the facility policy titled, Physical Environment Space and Equipment, dated 04/11/23, revealed inspection of resident care equipment will be completed routinely and as needed to ensure safe operating conditions. 4. During an observation on 03/26/24 at 9:15 A.M., Residents #29, #67, and #94 were at a dining tables with stains and food debris from the previous evening's meal. There were two left over food trays from the prior evening. During an interview at the the time of the observation, STNA #20 stated the facility dining staff is responsible for cleaning the dining room and the dining room had not been cleaned prior to breakfast. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 2 of 10 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 04/03/2024 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 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 review of hospital records, review of a Self-Reported Incident (SRI), staff interview, and policy review, the facility failed to accurately report an injury of unknown origin to the state agency. This affected one (Resident #337) of one resident reviewed for injuries of unknown origin. The facility census was 136. Findings include: Review of the closed medical record for Resident #337 revealed he was admitted to the facility on [DATE] and was discharged on 03/18/24. Diagnoses included peripheral vascular disease, chronic obstructive pulmonary disease, other hyperlipidemia, hypertensive heart disease with heart failure, spinal stenosis, bipolar disorder, type two diabetes mellitus without complications, anxiety disorder, chronic respiratory failure with hypoxia, atherosclerotic heart disease of native coronary artery without angina pectoris, and depression. Review of the five-day Minimum Data Set (MDS) assessment, dated 03/01/24, revealed this resident had moderately impaired cognition. This resident was assessed to require supervision for eating and oral hygiene, maximal assistance for bathing, upper body dressing, and bed mobility, and was dependent on staff for lower body dressing. Transfer was not attempted due to medical conditions or safety concerns. Review of the hospital records dated 03/05/24 revealed Resident #337 was diagnosed with a non-displaced occipital bone fracture. Review of an SRI dated 03/06/24 revealed the facility filed the SRI because Resident #337 was observed with a bruise above his left eye prior to being transferred to the hospital on [DATE]. The SRI does not include mention of a fracture. During an interview on 03/26/24 at 5:10 P.M., the Director of Nursing (DON) confirmed the SRI was filed related to the bruise on Resident #337's face. The DON stated she was focused on the bruise instead of the fracture, and verified the fracture should have been included in the SRI. During an interview on 03/27/24 at 2:20 P.M. with the DON revealed the fracture was thought to have occurred from a fall prior to admission and had not occurred at the facility. Review of the facility policy titled Abuse Prevention Program, revised March 2021, revealed an injury of unknown origin describes injuries that were not observed by any person, or the source could not be explained by a resident, and the injury was suspicious due to the extent of the injury, location of the injury, or the number of injuries observed at one point in time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 3 of 10 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 04/03/2024 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to thoroughly investigate an injury of unknown origin. This affected one (Resident #337) of one resident reviewed for injuries of unknown origin. The facility census was 136. Residents Affected - Few Findings include: Review of the closed medical record for Resident #337 revealed he was admitted to the facility on [DATE] and was discharged on 03/18/24. Diagnoses included peripheral vascular disease, chronic obstructive pulmonary disease, other hyperlipidemia, hypertensive heart disease with heart failure, spinal stenosis, bipolar disorder, type two diabetes mellitus without complications, anxiety disorder, chronic respiratory failure with hypoxia, atherosclerotic heart disease of native coronary artery without angina pectoris, and depression. Review of the five-day Minimum Data Set (MDS) assessment, dated 03/01/24, revealed this resident had moderately impaired cognition. This resident was assessed to require supervision for eating and oral hygiene, maximal assistance for bathing, upper body dressing, and bed mobility, and was dependent on staff for lower body dressing. Transfer was not attempted due to medical conditions or safety concerns. Review of the hospital records dated 03/05/24 revealed Resident #337 was diagnosed with a non-displaced occipital bone fracture. Review of the facility investigation dated 03/05/24 revealed no mention of Resident #337's fracture. Review of the investigation revealed witness statements had been typed up or written on a form and had not been signed by the employees that provided the information in the witness statements. The investigation also lacked statements from all staff involved. During an interview on 03/26/24 at 3:54 P.M., the Director of Nursing (DON) stated she had statements from staff through phone conversations that were not included in the facility's investigation. During an interview on 03/26/24 at 5:10 P.M., the DON confirmed the witness statements had not been signed by the employees involved and that there was no documentation in the investigation related to the fracture. Review of the facility policy titled Abuse Prevention Program, revised March 2021, revealed employee witnesses would be required to sign and date any witness report they made. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 4 of 10 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 04/03/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #124 revealed she was admitted to the facility on [DATE]. Diagnoses included unspecified dementia unspecified severity with other behavioral disturbance, chronic obstructive pulmonary disease, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, anxiety disorder, hypertensive heart disease without heart failure, hyperlipidemia, post-traumatic stress disorder, and depression. Residents Affected - Few Review of the quarterly MDS assessment, dated 03/14/24, revealed this resident had severely impaired cognition. Review of the PASARR dated 02/01/23 revealed Resident #124 had no diagnoses of post-traumatic stress disorder or depression. Interview on 03/28/24 at 1:19 P.M. with Social Services Director #717 confirmed the PASARR was incorrect due to missing diagnoses. Review of the policy titled Pre-admission Screening and Resident Review revealed the facility will review level 1 and level 2 assessments upon admission and are included in the resident's medical record. It is the policy of the facility to complete a Level 1 / Level 2 Assessment upon admission and as needed to ensure the specialized needs of residents. Based on record review, interview, and policy review the facility failed to ensure a valid Pre-admission Screen and Resident Review (PASARR) was completed for residents. This affected two (Residents #55 and #124) of three residents reviewed for PASARR status. The facility census was 136. Findings include: 1. Review of the medical record for Resident #55 revealed an admission date of 03/01/22. Diagnoses included major depressive disorder, single episode, unspecified and bipolar ii disorder. Review of the PASARR assessments revealed an assessment was completed on 03/01/22 for a less than 30 day stay and another assessments was completed on 05/23/23 for a stay more than 30 days. During an interview on 03/28/24 at 1:29 P.M., Social Service Director #717 confirmed the PASARR was not completed timely once Resident #55 stayed past 30 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 5 of 10 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 04/03/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, interview, and policy review, the facility failed to ensure resident care conferences were held quarterly. This affected three (Residents #109, #107, and #12) of three residents reviewed for care planning. The census was 136. Findings include: 1. Review of the medical record revealed Resident #109 was admitted on [DATE]. Review of the care plans for Resident #109 revealed no documentation a care plan conference was held between 01/11/23 and 12/27/23. During an interview on 03/27/24 at 3:01 P.M., Resident #109 stated he could not remember when his last care conference was held, but it had been a while back. 2. Record review revealed Resident #107 was admitted on [DATE]. Review of the care plans for Resident #107 revealed no documentation a care plan conference had been held between 09/16/22 and 03/28/24. During an interview on 03/28/24 at 8:56 A.M., Resident #107 stated she has never attended a care plan conference since her admission to the facility. 3. Record review revealed Resident #12 was admitted on [DATE]. Review of the care plans for Resident #12 revealed no documentation a care plan conference had been held between 01/11/23 and 12/27/23. There is not a documented care plan conference for 2024 as of 03/28/24. During an interview on 03/28/24 at 8:50 A.M., Resident #12 stated she has no memory of attending a care conference for a long time. During an interview on 03/28/24 at 8:43 A.M., MDS Coordinator #220 confirmed the Resident #109, #107 and !12 did not have care plan conferences quarterly as required. Review of the policy titled Care Planning, dated 09/28/21, revealed care plan meetings will be offered upon admission, quarterly, and as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 6 of 10 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 04/03/2024 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Potential for minimal harm Based on record review and interview, the facility failed to ensure nurse aides received a performance review at least every 12 months. This affected four (State Tested Nursing Assistants [STNA] #18, #50, #2 and #751) of four STNA personnel records reviewed. Residents Affected - Many Findings include: 1. STNA #18 was hired on 11/18/02. STNA #18 did not have an annual performance review for the period of 11/18/22 to 11/18/23. 2. STNA #50 was hired on 09/11/19. STNA #50 did not have an annual performance review for the period of 09/11/22 to 09/11/23. 3. STNA #2 was hired on 05/18/21. STNA #2 did not have an annual performance review for the period of 05/18/22 to 05/18/23. 4. STNA #751 was hired on 02/11/02. STNA #751 did not have an annual performance review for the period of 02/11/23 to 02/11/24. During an interview on 03/28/24 at 1:59 P.M., Human Resources Manager #62 confirmed annual performance reviews were not completed for STNA #18, STNA #50, STNA #2 and STNA #751 during their most recent anniversary year. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 7 of 10 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 04/03/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, record review, and interview, the faciltiy failed to serve residents their preferred food items. This affected three (Residents #38, #70, and #72) of three residents reviewed for meal preferences. Ths facility census was 136. Findings include: Review of Resident Council Meeting Minutes revealed on 12/28/23 residents complained about not getting the items listed on their meal tickets. On 02/23/24 residents again complianed the meals did not match what is on the meal tickets that they filled out. During an observation on 03/27/24 at 9:12 A.M., Resident #38's meal ticket had her food choices as grapes, orange slices, skim milk, eggs with cheese on them and corn flakes cereal. Observation of Resident #28's breakfast tray revealed she received received strawberries, two percent milk, eggs without cheese and no cereal. During an observation on 03/27/24 at 9:20 A.M., Resident #70's meal ticked had his food choices as scrambled eggs and orange juice. He received fried eggs and cranberry juice. During an observaiton on 03/27/24 at 9:32 A.M., Resident #72's meal ticket had his food choices as bacon or sausage. He received neither items on his breakfast tray. During an interview on 03/27/23 at 9:32 A.M., Licensed Practical Nurse (LPN) #32 confirmed the residents did not receive the items on their breakfast trays they had requested. During an interview on 03/25/24 at 1:23 P.M., Resident #72 stated his food is cold and doesn't arrive on time. The food he receives doesn't match the meal ticket he fills out. Snacks are never provided or offered. During an interview on 03/25/24 at 3:06 P.M. Resident #70 stated the food was awful. He does not get the items he requests on his meal ticket. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 8 of 10 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 04/03/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, record review and interview, the facility failed to maintain a clean, sanitary kitchen area, failed to properly store food, failed to maintain an effective pest control program and failed to maintain a current food service license. This affected all residents in the facility except three (Residents #26, #81, #236) who did not receive food from the kitchen. The facility census was 136. Findings include: 1 Review of the facility's food service license on 03/25/24 at 8:23 A.M. revealed it had expired on 03/01/24. During an interview on 03/27/23 at 4:10 P.M., a representative from the local health department verified the facility failed to renew their food service license. 2. During observations on 03/25/24 at 8:23 A.M., there was food splatter and debris up and down the kitchen wall at the hand wash sink. There was debris caked on the plate warmer and down the front of the ice machine. Walk in refrigerator #01 contained a large metal pan of scrambled eggs with no label, eight large metal cookie sheets with cookies and no label, two large cookie sheets with four covered, unlabeled pies, half a sliced onion with no label, a large metal pain of sliced tomatoes with no label, a large pan of lettuce with no label, and a large, opened carton of eggs with no label. Walk in refrigerator #02 contained a large metal pan of hot dogs with no label, and a large container of unknown substance that appeared to be tuna fish with no label and a large metal pan with mashed potato with no label. The freezer contained a large, opened bag of frozen veggies in a box, unsealed and undated. There were boxes stored on the floor of the freezer. The kosher kitchen refrigerator contained a large metal container of sliced meat with no label and a container of cooked rice with no label. The kosher kitchen freezer contained a large open bag of French fries with no label. Dietary [NAME] (DC) #400 verified the above findings at the time of the observations. Review of the facility policy titled, Food Storage, dated October 2018, revealed items removed from original packaging will be dated with the date of delivery. Further review of the facility policy revealed open containers will be resealed in a manner that protects the remaining food products and will be dated with the opening date. 3. During observation on 03/25/24 at 8:40 A.M. with the DC #400 asked for the assistance of Dietary Aide (DA) #530. During an interview on 03/25/24 at 8:44 A.M., DA #530 stated her usual kitchen task was to run the dishes through the dishwasher at the facility. DA #530 stated the required wash cycle temperature was 160 degrees Fahrenheit (F) and the rinse cycle was 180 degrees F. DA #530 attempt to run the dishwasher four to five times. The wash cycle temperature never reached 160 degrees F. During an interview on 03/25/24 at 10:20 A.M., Maintenance Supervisor (MS) #905 confirmed the dishwasher did not reach the required temperature of 160 degrees F on the wash cycle. MS #905 stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 9 of 10 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 04/03/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many dishwasher does have a booster to ensure it reaches the correct temperature. MS #905 stated the booster was not turned on. 4. Review of the pest control invoice dated 12/21/23, documented water on the floor, standing water on the floor in the dish area and floor drains had debris in them. On 01/18/24, the invoice stated the floor sink drain has debris in the sink area and standing water in the dish area. On 01/25/24, the invoice stated the floor sink drains have debris in the sink dish area, and standing water. On 02/24/24, the invoice stated the facility had standing water on the floor in the dish area and the facility should improve drainage. During an observation on 03/25/24, a large swarm of drain flies flew up from the drain as Dietary Aide (DA) #530 turned on the dishwasher. DA #530 confirmed the large amount of food debris and dirt scattered along the top of the dishwasher. Review of the facility policy titled, Pest Control Program, dated 04/11/23, revealed the facility will maintain an effective pest control program that eradicates and contains common household pets and rodents. 5. During observation on 03/25/24 at 10:20 A.M., Maintenance Supervisor (MS) #905 was repairing the dishwasher. The dishwasher parts were covered a brown substance. MS #905 stated the brown substance was a large amount of lime buildup. MS #905 stated the facility had failed to maintain the cleanliness of the dishwasher resulting in lime build up on the heating elements. This could attribute to the dish machine not reaching the correct temperature. 6. During observation on 03/27/24 at 12:09 P.M. there was food debris, splatter, spills running down the trash cans throughout the kitchen. and brown food debris and splatter along the walls over the food preparation areas. The ceiling lights in the tray line area had bugs in them. The ceiling tiles in the food tray line area were soiled and heavily splattered with a brown unknown substance. During interview at the time of the observation, Dietary Manager (DM) #870 confirmed the above findings. Review of the facility policy titled, Kitchen Sanitation, dated 11/07/23, revealed the purpose of the policy was to ensure food and supplies will be handled in a sanitary environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366120 If continuation sheet Page 10 of 10