Inspection Reports for
Majestic Care of Cedar Village
5467 CEDAR VILLAGE DRIVE, MASON, OH, 45040
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
6.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
151% occupied
Based on a September 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 142
Deficiencies: 4
Date: Sep 4, 2025
Visit Reason
The inspection was conducted in response to complaints alleging staff qualification issues, medication administration failures, infection control lapses, and pest control problems at the facility.
Complaint Details
The deficiencies were investigated under Complaint Numbers 1359585 (OH00162141), 2580789, and 1359582 (OH00162827).
Findings
The facility failed to ensure nurse aides were properly trained and competent, medication was administered as ordered, infection prevention protocols were followed, and the environment was free from pests. These deficiencies affected multiple residents and units within the facility.
Deficiencies (4)
F 0728: The facility failed to ensure nurse aides who worked more than 4 months were trained and competent; one aide worked beyond allowed period without passing the state CNA test. This potentially affected all 142 residents.
F 0755: The facility failed to provide pharmaceutical services to meet resident needs; one resident did not receive ordered vitamin medication for multiple days due to pharmacy supply issues and lack of communication.
F 0880: The facility failed to implement infection prevention and control; staff did not perform hand hygiene properly, touched medications with bare hands, failed to clean glucometer between residents, and medication carts were unsanitary. This affected multiple residents and units.
F 0925: The facility failed to maintain an effective pest control program; gnats and ants were observed on food trays and dining areas, affecting all 142 residents.
Report Facts
Facility census: 142
Medication non-administration days: 25
Medication non-administration days: 17
Residents affected by infection control issues: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #540 | Nursing Assistant | Worked beyond allowed period without passing CNA state test |
| LPN #238 | Licensed Practical Nurse | Reported medication not available and not administered as ordered for Resident #3 |
| Pharmacist #153 | Pharmacist | Verified pharmacy did not supply prescribed medication for Resident #3 |
| DON | Director of Nursing | Verified medication administration failures and infection control issues |
| CNA #374 | Certified Nurse Assistant | Observed failing to perform hand hygiene during incontinent care for Resident #104 |
| LPN #455 | Licensed Practical Nurse | Observed and verified hand hygiene lapses and unsanitary medication carts |
| LPN #336 | Licensed Practical Nurse | Observed touching medications with bare hands and not cleaning glucometer between residents |
| LPN #414 | Licensed Practical Nurse | Confirmed presence of gnats on resident meal trays |
| LPN #305 | Licensed Practical Nurse | Observed gnats on juice machine spouts |
Inspection Report
Complaint Investigation
Census: 137
Deficiencies: 1
Date: Aug 15, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to the facility's kitchen sanitation and food safety practices.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00156079.
Findings
The facility failed to maintain a clean and sanitary kitchen area, evidenced by a large swarm of small flying insects around exposed potatoes. This posed a potential risk to 133 residents receiving meals in the facility.
Deficiencies (1)
F 0812: The facility failed to procure food from approved sources and did not store, prepare, distribute, and serve food in accordance with professional standards. A swarm of flying insects was observed around exposed potatoes stored improperly in the kitchen.
Report Facts
Residents affected: 133
Facility census: 137
Residents not receiving food from kitchen: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nutritional and Food Services | Confirmed presence of flying insects and improper storage of potatoes during interview |
Inspection Report
Complaint Investigation
Census: 132
Deficiencies: 2
Date: Apr 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation under Complaint Number OH00152801 regarding pressure ulcer care and medication administration errors at Majestic Care of Cedar Village.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00152801.
Findings
The facility failed to provide appropriate pressure ulcer care for Resident #20, resulting in actual harm and hospitalization due to wound infection and possible osteomyelitis. Additionally, medication errors occurred affecting Residents #30 and #75, with an error rate of 11.5%, exceeding the acceptable threshold.
Deficiencies (2)
F 0686: The facility failed to ensure residents received necessary treatment and services to promote healing and prevent infections for a pressure ulcer. Resident #20's weekly skin assessments were not completed, leading to hospitalization for wound infection and possible osteomyelitis.
F 0759: The facility failed to ensure medication error rates were less than 5%, with incorrect medication administration for Residents #30 and #75 and failure to administer a medication for Resident #75. There were three errors out of 26 opportunities for a medication error of 11.5%.
Report Facts
Facility census: 132
Medication error rate: 11.5
Medication administration opportunities: 26
Medication errors: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #10 | Registered Nurse | Named in medication error finding for Resident #30 and interview regarding wound care. |
| LPN #11 | Licensed Practical Nurse | Wound certified nurse involved in wound care rounds and interview regarding wound assessments for Resident #20. |
| LPN #15 | Licensed Practical Nurse | Named in medication error finding for Resident #75. |
| Director of Nursing | Director of Nursing | Interviewed regarding wound assessments and care for Resident #20. |
Inspection Report
Routine
Census: 136
Deficiencies: 9
Date: Apr 3, 2024
Visit Reason
Routine inspection of Majestic Care of Cedar Village nursing home to assess compliance with regulatory requirements including resident rights, safety, care planning, staff performance, food service, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to facilitate resident room changes, maintain resident equipment and dining cleanliness, timely report and investigate injuries of unknown origin, complete PASARR screenings, hold quarterly care conferences, conduct annual nurse aide performance reviews, serve residents preferred food items, and maintain a clean and sanitary kitchen with proper food storage and pest control.
Deficiencies (9)
F 0561: The facility failed to initiate a requested room change for Resident #18, violating resident self-determination rights.
F 0584: The facility failed to ensure resident equipment was in good repair and failed to keep the dining room clean, affecting six residents.
F 0609: The facility failed to accurately report an injury of unknown origin involving Resident #337 to the state agency.
F 0610: The facility failed to thoroughly investigate an injury of unknown origin involving Resident #337, lacking signed witness statements and documentation of fracture.
F 0645: The facility failed to ensure valid PASARR screenings were completed timely for residents #55 and #124.
F 0657: The facility failed to hold quarterly care conferences for residents #109, #107, and #12 as required.
F 0730: The facility failed to ensure nurse aides received annual performance reviews for four STNAs.
F 0806: The facility failed to serve residents their preferred food items, affecting three residents.
F 0812: The facility failed to maintain a clean, sanitary kitchen, properly store food, maintain an effective pest control program, and maintain a current food service license, affecting all residents except three.
Report Facts
Residents affected: 1
Residents affected: 6
Residents affected: 1
Residents affected: 2
Residents affected: 3
Staff affected: 4
Residents affected: 3
Facility census: 136
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director #717 | Social Service Director | Interviewed regarding room change, PASARR screening, and care conferences |
| Licensed Practical Nurse #32 | Licensed Practical Nurse | Interviewed regarding room change and meal preferences |
| Director of Nursing | Director of Nursing | Interviewed regarding injury reporting and investigation |
| State Tested Nursing Assistant #18 | STNA | Confirmed equipment and dining room deficiencies, affected by lack of performance review |
| Human Resources Manager #62 | Human Resources Manager | Confirmed lack of annual performance reviews for STNAs |
| Dietary Aide #530 | Dietary Aide | Confirmed dishwasher temperature issues and kitchen cleanliness |
| Maintenance Supervisor #905 | Maintenance Supervisor | Confirmed dishwasher malfunction and lime buildup |
| Dietary Manager #870 | Dietary Manager | Confirmed kitchen sanitation deficiencies |
Inspection Report
Complaint Investigation
Census: 139
Deficiencies: 1
Date: Oct 11, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to a medication error incident involving Resident #51 receiving medications prescribed for another resident.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00146375.
Findings
The facility failed to ensure medications were administered without significant errors, affecting one resident. The medication error was identified, reported, and corrected with no adverse effects noted on the resident.
Deficiencies (1)
F 0760: The facility failed to ensure residents were free from significant medication errors. Resident #51 received medications prescribed for Resident #141 in error on 09/09/23. The error was reported and corrected with monitoring and no adverse effects noted.
Report Facts
Facility census: 139
Medications observed during medication pass: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #337 | Licensed Practical Nurse | Administered wrong medications to Resident #51 and reported the error |
| DON | Director of Nursing | Notified of medication error and confirmed monitoring and corrective actions |
Inspection Report
Complaint Investigation
Census: 148
Deficiencies: 4
Date: May 17, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on allegations of call light accessibility issues, failure to report suspected abuse, and inadequate assistance with eating for residents.
Complaint Details
The complaint investigation involved issues with call light accessibility for Resident #128 and allegations of emotional/verbal abuse involving Resident #94 and Unit Manager #236. The facility failed to report the abuse allegations to the State Survey Agency and Ohio Department of Health and did not conduct a thorough investigation, resulting in psychosocial harm to Resident #94.
Findings
The facility failed to ensure a resident's call light was within reach, failed to report and investigate allegations of resident abuse properly, and failed to provide appropriate assistance with meals to a resident requiring extensive help. These deficiencies affected specific residents and resulted in minimal to actual harm.
Deficiencies (4)
F 0558: The facility failed to ensure Resident #128's call light was within reach per the plan of care, affecting one resident. The call light was found behind and under the bed and out of reach.
F 0609: The facility failed to timely report allegations of resident abuse to the State Survey Agency and Ohio Department of Health, affecting one resident. No reports were filed regarding alleged emotional/verbal abuse.
F 0610: The facility failed to protect Resident #94 from abuse during an investigation and failed to conduct a thorough abuse investigation, resulting in psychosocial harm including fear, agitation, and tearfulness.
F 0677: The facility failed to ensure Resident #128 received appropriate assistance with eating as required. The resident was offered fluids but not food after waking up, contrary to facility policy.
Report Facts
Facility census: 148
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| UM #236 | Unit Manager | Named in abuse allegation and investigation findings |
| LPN #356 | Licensed Practical Nurse | Reported resident concerns about abuse and confirmed details of abuse allegations |
| STNA #217 | State Tested Nursing Assistant | Interviewed regarding call light accessibility and meal assistance for Resident #128 |
| DON | Director of Nursing | Interviewed regarding abuse allegations, investigation, and meal assistance policies |
| SW #347 | Social Worker | Interviewed regarding abuse allegations and resident interviews |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 13, 2023
Visit Reason
Annual inspection survey of Majestic Care of Cedar Village nursing home.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 143
Deficiencies: 9
Date: Jun 14, 2021
Visit Reason
The inspection was conducted based on multiple complaints regarding resident care, housekeeping, medication administration, pest control, and facility cleanliness.
Complaint Details
The deficiencies substantiate multiple complaint numbers OH00115194, OH00114155, OH00112495, and OH00115360.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident privacy, inadequate housekeeping and sanitation, failure to provide required baths/showers, medication errors, improper medication storage, unclean dining areas, and presence of flying insects (gnats) in resident care areas.
Deficiencies (9)
F0550: The facility failed to ensure a resident's Foley catheter bag was covered for privacy, affecting one resident with an indwelling catheter.
F0584: The facility failed to maintain residents' rooms in a clean and sanitary manner, affecting nine residents in the Redbud building.
F0677: The facility failed to provide baths/showers to residents dependent on staff for care, affecting four of six sampled residents.
F0685: The facility failed to provide eyeglasses daily to a resident dependent on staff for vision, affecting one resident.
F0759: The facility failed to administer medications per physician orders, resulting in a medication error rate of 8%, affecting one resident.
F0760: The facility failed to correctly transcribe physician admission orders, resulting in residents not receiving prescribed medication, affecting one resident.
F0761: The facility failed to ensure medications were disposed of if outdated and not in circulation, potentially affecting all 143 residents.
F0921: The facility failed to maintain the resident dining rooms in a clean and sanitary manner, affecting 15 residents in the Redbud building and potentially others.
F0925: The facility failed to eradicate flying insects (gnats) in resident care areas, affecting 42 residents on two units.
Report Facts
Residents affected: 143
Medication error rate: 8
Residents affected by housekeeping issues: 9
Residents affected by bathing deficiencies: 4
Residents affected by eyeglasses issue: 1
Residents affected by dining room cleanliness: 15
Residents affected by pest control issue: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #147 | Licensed Practical Nurse | Named in medication administration error involving eye drops |
| RN #187 | Registered Nurse | Confirmed accuracy of shower sheets and dining room cleanliness observations |
| Director of Nursing | Verified facility standards for catheter bag covers and eyeglasses use; discussed medication audits and housekeeping staffing | |
| Housekeeping Supervisor #69 | Housekeeping Supervisor | Reported housekeeping staffing shortages and cleaning schedules |
| Registered Nurse #129 | Registered Nurse | Produced original transfer orders revealing transcription error |
| State Tested Nurse Aide #115 | State Tested Nurse Aide | Interviewed regarding bathing schedules and catheter bag coverage |
Inspection Report
Complaint Investigation
Census: 142
Deficiencies: 1
Date: Jan 30, 2020
Visit Reason
The inspection was conducted due to a complaint regarding a staff member making an inappropriate comment to a resident.
Complaint Details
The complaint was substantiated based on interviews with the resident, staff, and policy review confirming the inappropriate comment made by a State Tested Nursing Aide.
Findings
The facility failed to ensure a resident was treated with respect when a staff member made an inappropriate comment about amputating the resident's leg. Interviews and policy review confirmed the statement was inappropriate and violated resident dignity.
Deficiencies (1)
F 0550: The facility failed to honor the resident's right to dignity and respect when a staff member made an inappropriate comment to Resident #274 about cutting off his leg. The comment was acknowledged as inappropriate by staff and contradicted facility policy on resident dignity.
Report Facts
Facility census: 142
Viewing
Loading inspection reports...
