Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Majestic Care Of Cedar Village. during CMS and state inspections, most recent first.
Food was not served at appropriate and safe temperatures during tray line service. A pan of yogurt cups was left on the tray line counter without ice or another cooling method, and a test tray later showed eggs at 110 degrees F and yogurt at 64 degrees F. The DON verified the temperatures and stated the eggs should have been 135-140 degrees F and the yogurt 45 degrees F or less when served. A resident also stated her breakfast eggs were not hot enough and that food tends not to be served very hot.
Unsafe food handling and sanitation practices were observed throughout the kitchen and on the tray line. Juice cups were left uncovered while being delivered to residents, a dietary aide and an unidentified staff member were observed without proper hair restraints, gloves were used improperly without hand hygiene, a dirty fan was blowing into the tray line, a unit refrigerator contained yellow liquid, clean stock pots were placed on the floor while being filled, and a CNA used bare hands to prepare a resident’s banana.
Resident Council concerns were not addressed or tracked in meeting minutes for multiple residents who regularly attended. Residents said the Administrator ran the meetings, concerns were not followed up on, and prior issues never appeared as old business or with documented resolution in later meetings. The AD and Administrator both confirmed the minutes lacked evidence of resident concern resolution.
High temperatures on the Apple unit left several resident rooms, the corridor, and the dining room well above the facility’s comfort range. An MTD verified the heat with an infrared thermometer, and residents said it was terribly hot. The ADM stated the AC was not operating, portable units and fans were later brought in, but ambient temperatures were not monitored or documented as required by the facility’s extreme temperature response plan.
Failure to Timely Report Alleged Misappropriation: A cognitively intact resident reported that $30 in cash was missing from his room after returning from the hospital. The DON/Administrator did not report the allegation to the State Agency in a timely manner, stating he learned of it much later and did not file an SRI because too much time had passed, despite facility policy requiring alleged misappropriation to be reported within 24 hours of the care team being notified.
Failure to provide routine dental services affected two residents. One resident with multiple neurologic and psychiatric diagnoses had documented oral/dental problems, but the record showed no dental visits for over a year and the DON confirmed no dental services since the last recorded exam. Another resident with diabetes, PVD, kidney disease, chronic pain, and anxiety had missing teeth and bone loss; after refusing the facility clinic dentist, there were no documented follow-up attempts to secure outside dental care, and staff interviews showed delays and missed scheduling opportunities.
Failure to provide quarterly therapy screening for a resident with DM2, COPD, CHF, CKD, and anxiety. The resident’s care plan called for routine therapy screening, evaluation, and treatment as ordered, but after PT/OT ended due to lack of progress and participation, the resident was not re-evaluated for therapy services. The resident reported arm weakness from being in bed and said he could use therapy, and the DTR confirmed no therapy evaluation had occurred since discharge despite the expectation for quarterly screens.
A nursing assistant who had completed CNA coursework but had not passed the state certification test was allowed to work as a CNA for longer than the four months permitted for uncertified aides. Human Resources confirmed the staff member continued working past the allowed period, resulting in non-compliance with staff qualification requirements and potentially affecting all residents.
Multiple observations revealed gnats and ants present on food trays and in dining areas, with trays left out from previous meals and pests confirmed by the DON, residents, and LPNs. Despite a pest control policy and cleaning schedules, pests were found on trays, food, and juice machine spouts, indicating ineffective pest management.
Staff failed to perform hand hygiene during incontinent care, handled medications with bare hands, and did not clean a shared glucometer between residents. Additionally, medication carts were found to be unsanitary, with loose pills and debris present. These deficiencies were confirmed through observation and staff interviews, affecting multiple residents and units.
A resident with multiple chronic conditions did not receive a prescribed combination tablet of folic acid, vitamin B6, and vitamin B12 as ordered, due to the medication not being available in the facility. Only the evening dose was administered, while the morning dose was missed on several dates. Staff interviews revealed that the correct medication was not supplied by the pharmacy, and there was no documented communication with the physician or pharmacy regarding the medication's unavailability or the need for refills.
The facility failed to maintain a clean kitchen area, potentially affecting 133 residents. Observations revealed a swarm of insects around exposed potatoes stored improperly. The Director of Nutritional and Food Services confirmed the issue, acknowledging improper storage practices.
A resident with multiple diagnoses, including diabetes and chronic kidney disease, developed a severe wound infection and possible osteomyelitis due to the facility's failure to complete weekly skin assessments and ensure timely wound care. The resident missed two wound clinic appointments, leading to hospitalization and a diagnosis of a right heel pressure ulcer with wet necrosis and suspected superimposed infection/osteomyelitis.
The facility failed to maintain medication error rates below 5%, resulting in an 11.5% error rate. Two residents received incorrect medications due to staff not following physician orders and facility policy.
Food Served at Unsafe Temperatures
Penalty
Summary
Food was not served at appropriate and safe temperatures during tray line service. During observation on 06/10/26 at 7:49 A.M., a large pan of individually scooped and covered plastic cups identified by Dietary Aid #690 as yogurt was sitting on the counter in the tray line area with no ice or other method used to keep the contents cold, and it remained there throughout the entire tray line service. A test tray reviewed later that morning showed eggs at 110 degrees Fahrenheit and yogurt at 64 degrees Fahrenheit. The Director of Nutrition and Food Service verified those temperatures and stated the eggs should have been at least 135-140 degrees Fahrenheit and the yogurt 45 degrees Fahrenheit or less when it reached residents. Resident #39 stated at 11:44 A.M. that her breakfast eggs were not hot enough and that the food tends not to be served very hot. The facility policy titled Food Production stated food would be served at appropriate temperatures.
Unsafe Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to prepare, serve, and store food in a manner to prevent the potential spread of foodborne illness. During observation, a cart with approximately 25 cups of juice was left in the hallway in front of the nurse station on the [NAME] unit with the cups covered only by loose paper towels. CNAs were observed removing the cups from the cart, placing them on resident lunch trays, and carrying the trays down the hall to resident rooms with the juice cups uncovered. A CNA confirmed the cups were covered with paper towels in the hallway and were not covered once removed from the cart, and the RD verified beverages should be covered when being taken down the hall to resident rooms. Food handling practices were also observed to be unsanitary in the kitchen and on the tray line. A dietary aide stirring and serving hot cereal had long hair tied back in a ponytail extending several inches down her back and was not wearing a hairnet. An unidentified person in scrubs entered the kitchen near the active breakfast tray line with multiple braids and did not apply a hair restraint upon entering. The DNFS observed the person and directed her to obtain a hairnet, and later stated the person was a nursing assistant from assisted living but did not know her name. Additional observations showed improper glove use, poor sanitation, and unsafe handling of clean equipment and food. A dietary aide touched a potentially soiled surface with a gloved hand and then handled pancakes directly with the same glove, then removed her gloves and applied a clean pair without performing hand hygiene and stated she had nothing available to sanitize her hands. A dirty fan was positioned on milk crates blowing into the tray line area, a pantry refrigerator on the Peach unit contained yellow liquid in the drawers and bottom, and a staff member placed clean stock pots on the floor while filling them with water before returning them to the stove. A CNA also used bare hands to unpeel a banana and place it on a resident's plate while setting up a breakfast tray.
Resident Council Concerns Not Documented or Resolved
Penalty
Summary
The facility failed to consider and timely resolve resident concerns raised in Resident Council meetings, affecting twelve residents who regularly attended. During a Resident Council discussion with three residents, the Administrator was reported to attend and run the meetings, and the residents stated their concerns were not addressed, there was no follow-up, and issues raised in one meeting were never included in subsequent meetings with information on resolution. Review of Resident Council meeting minutes from May 2025 through May 2026 showed no documented old business and no documented evidence of discussion or resolutions to concerns that had been brought up. The Activity Director stated the Administrator ran the meetings and documented the minutes, and confirmed there was no old business documented and no documented resolution of resident concerns. The Administrator also stated he attended the meetings and compiled the minutes, and verified there was no documented evidence of resolutions from resident concerns brought up in the meetings.
High Temperatures on Apple Unit
Penalty
Summary
The facility failed to maintain a comfortable environmental temperature on the Apple nursing unit. During a tour, the main corridor on the unit measured 84.9 degrees Fahrenheit, the dining room measured 89.8 degrees Fahrenheit, and resident rooms for six residents measured between 83.3 and 85.6 degrees Fahrenheit. The temperatures were taken and verified by the Maintenance Director using the facility’s infrared thermometer. Interviews with three residents on the unit revealed that it was terribly hot in their rooms. The Maintenance Director confirmed that the temperatures on the Apple nursing unit and in the affected resident rooms were not homelike or comfortable, and also stated that ambient air temperatures had not been documented on the Apple nursing unit or the other four potentially affected nursing units. The Administrator stated the air conditioning problem on the Apple nursing unit began when he was notified that the system was not operating, portable air conditioning units and fans were later brought in, and the Maintenance Director did not monitor and document environmental temperatures as required by the facility’s Extreme Temperature response plan. The Administrator also stated he did not report the situation to the Regional President of Operations until several days later. Facility policies required a safe, comfortable environment and stated that common resident areas should be maintained between 71 and 81 degrees Fahrenheit.
Failure to Timely Report Alleged Misappropriation
Penalty
Summary
The facility failed to report an allegation of misappropriation to the State Agency within the required timeframe. Resident #55, who was cognitively intact and had diagnoses including Type II diabetes, peripheral vascular disease, unspecified kidney disease, chronic pain syndrome, and unspecified anxiety disorder, reported that $30.00 was missing from under the lamp in his room after returning from the hospital. He stated the money had been kept as one $5 bill and twenty-five $1 bills, and he also said a friend outside the facility knew about the money, although this could not be confirmed. The Administrator offered a safe alternative for storing the resident’s belongings, but the resident refused. The facility reviewed the concern and interviewed staff, none of whom were aware of the missing money. The Administrator stated he could not replace the $30.00 because he could not confirm the resident had it, but he later purchased snacks in an amount equivalent to $30.00 and delivered them to the resident, who agreed to that exchange. During interview, the Administrator stated the allegation was brought to his attention much later than the alleged incident, that the Ombudsman emailed him about it in February 2026, and that he did not file an SRI because too much time had passed. Facility policy required alleged misappropriation to be investigated and reported to the Department of Health within 24 hours of the care team being notified of the allegation.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure routine dental services were provided to two sampled residents. Resident #12 had diagnoses including unspecified cerebrovascular disease, chronic pulmonary embolism, paranoid schizophrenia, mild vascular dementia with psychotic disturbance, and unspecified seizures. The care plan identified oral/dental health problems related to missing teeth and a history of mouth pain, with interventions to coordinate dental care and transportation, observe and report dental problems, and encourage mouth care twice daily. However, the record contained no progress notes for dental visits in the last 12 months, and the dental treatment record showed the last dental examinations were on 07/20/22, 01/31/23, and 03/20/24. During interview, Resident #12 stated she could not remember the last time she saw a dentist and reported difficulty chewing, and the DON verified the resident had not had dental services since 03/20/24. Resident #55 had diagnoses including Type II Diabetes, peripheral vascular disease, unspecified kidney disease, chronic pain syndrome, and unspecified anxiety disorder. The care plan identified oral/dental problems due to missing teeth and included coordinating appointments and transportation for dental care, observing and reporting dental concerns, and encouraging mouth care twice daily. The resident had a dental examination through the facility clinic on 11/05/25, which noted multiple missing teeth, existing restorations, and moderate bone loss, but the recommendations were illegible. On 04/02/26, Resident #55 refused dental services through the facility clinic, and there were no additional notes showing attempts to schedule dental services. The resident stated he had been trying for months to get an outside dental appointment and was told the only local dentist accepting Medicaid was booked for five months. Staff interviews confirmed the resident did not want the facility clinic dentist, that outside appointments were handled by Medical Records, and that Medical Records did not become aware of the need for an outside appointment until the resident asked at the beginning of June 2026; the first provider contacted had no June availability, and no first-available appointment was scheduled at that time.
Failure to Provide Quarterly Therapy Screening
Penalty
Summary
The facility failed to provide quarterly screening for therapy services for one resident. Resident #7 was admitted with diagnoses including Type II diabetes, COPD, chronic diastolic heart failure, unspecified anxiety disorder, and unspecified chronic kidney disease. The most recent MDS showed the resident was cognitively intact, had no behaviors, did not wander, and frequently rejected care. The care plan stated the resident required assistance with ADLs and included interventions for therapy to screen routinely, evaluate, and treat as ordered. The resident received PT and OT from 09/23/25 to 10/16/25 and was discharged because of lack of progress and lack of compliance/participation in therapy. During an interview, the resident stated his arms were getting weaker from being in bed and that he could use therapy. The Director of Therapy Services confirmed the resident had not been evaluated for therapy services since discharge in October 2025 and stated each resident was supposed to be screened quarterly. The facility policy also stated quarterly facility-wide screens were conducted to identify residents who might benefit from skilled therapy.
Unqualified Nursing Assistant Worked Beyond Permitted Timeframe
Penalty
Summary
The facility failed to ensure that a nursing assistant was properly qualified to provide resident care, as required by regulations. Record review showed that a nursing assistant was hired after completing a CNA course but had not passed the state certification test. Despite this, the staff member worked as a CNA for a period exceeding the four months allowed for individuals who have not yet obtained certification. Human Resources confirmed that the nursing assistant continued to work past the permitted timeframe without having passed the state test, resulting in non-compliance with staffing qualification requirements. This issue had the potential to affect all 142 residents in the facility, as the staff member was involved in direct resident care.
Failure to Maintain Pest-Free Environment in Dining Areas
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by multiple observations of gnats and ants present on food trays and in dining areas. During an initial tour with the DON, dinner trays from the previous day were found in the Gardenia, Apple, and Peach unit dining areas, with gnats and ants observed on the trays and food. The DON confirmed the presence of these pests during the tour. Further observations included gnats on a resident's meal tray while eating breakfast, with both the resident and an LPN confirming that gnats are often present. Additional inspection revealed multiple gnats on all four spouts of a juice machine in the Peach unit, with confirmation from another LPN. Review of pest control work orders indicated recent treatment for gnats and ants, though light gnat activity was still noted and no ant activity was observed at that time. Cleaning schedules indicated that dining rooms are to be cleaned after each meal and trays taken to the kitchen, but trays were found left out with food and pests present. The facility's pest control policy states an intent to eradicate and contain pests, but the observations and interviews demonstrate that pests were not effectively controlled, affecting all residents in the facility.
Infection Control and Medication Administration Deficiencies
Penalty
Summary
Staff failed to follow proper infection prevention and control protocols during resident care and medication administration. During incontinent care for a resident with multiple comorbidities, including diabetes mellitus, ulcerative colitis, and morbid obesity, a CNA did not perform hand hygiene after removing soiled gloves and before donning new gloves. The CNA also failed to perform hand hygiene after removing gloves a second time and exiting the resident's room to provide a shower. These actions were observed and confirmed by an LPN, and were not in accordance with the facility's hand hygiene policy, which requires handwashing before and after direct resident contact and after glove removal. Medication administration practices were also found to be deficient. An LPN was observed removing multiple medications from pill cards with bare hands and physically touching each pill before administering them to three different residents. Additionally, the same LPN failed to clean a multi-resident blood glucometer between uses on different residents, despite being aware that the glucometer should be sanitized after each use. These practices were confirmed through staff interviews and were not consistent with infection control standards. Environmental sanitation issues were identified in the medication storage areas. The medication cart on one unit, which served 26 residents, was found to contain loose and broken tablets, as well as a significant accumulation of pill fragments and debris under the medication cards. Staff interviews confirmed that cleaning tasks were assigned but not consistently completed, and the Director of Nursing acknowledged that medication carts should be routinely cleaned and free of loose medications. Facility policies required proper storage and sanitation of medications, which was not maintained.
Failure to Provide and Administer Prescribed Medication Due to Lack of Availability and Communication
Penalty
Summary
The facility failed to ensure that a resident received medication as ordered by the physician, specifically a combination tablet of folic acid, vitamin B6, and vitamin B12, prescribed to be administered twice daily. Medical record review showed that the resident, who had multiple diagnoses including irritable bowel syndrome, hypothyroidism, chronic kidney disease, and chronic congestive heart failure, did not receive the morning dose of the prescribed medication on numerous dates in July and August. The Medication Administration Record (MAR) indicated that only the evening dose was consistently administered, while the morning dose was missed on several occasions. Interviews with staff revealed that the prescribed medication was not available in the facility, and the over-the-counter alternative did not match the required formulation, so it was not administered. The LPN could not recall if the physician or pharmacy was notified about the unavailability of the medication. The pharmacist confirmed that the pharmacy did not supply the required medication, and the DON verified that there was no documentation of communication with the physician or pharmacy regarding the missing medication or need for refills. The DON also could not confirm what medication, if any, was being administered in place of the prescribed formula.
Sanitation Deficiency in Kitchen Area
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen area, which had the potential to affect 133 residents who received meals from the kitchen. During an observation, a large swarm of small flying insects was found around two boxes of exposed potatoes stored openly under a window and near the ice machine. The Director of Nutritional and Food Services confirmed the presence of the insects and acknowledged that the potatoes should not have been stored in that manner. This deficiency was investigated under Complaint Number OH00156079.
Failure to Provide Necessary Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that Resident #20 received the necessary treatment and services to promote healing and prevent infections for a pressure ulcer. Resident #20, who had multiple pertinent diagnoses including type two diabetes mellitus with diabetic neuropathy and chronic kidney disease, was admitted to the facility with a right large heel pressure ulcer. Despite having a care plan in place that included regular skin assessments and wound care, the facility did not complete weekly skin assessments from 03/13/24 to 04/08/24. This lapse in care led to the resident developing a wound infection and possible osteomyelitis, resulting in hospitalization on 04/09/24. The resident's wound measurements were not documented during this period, and the resident missed two wound clinic appointments due to feeling unwell, which further exacerbated the situation. The facility's Director of Nursing confirmed the lack of wound assessments during this critical period. The resident's condition deteriorated, leading to a hospital diagnosis of a right heel pressure ulcer with wet necrosis and suspected superimposed infection/osteomyelitis. Hospital records revealed the presence of Methicillin Resistant Staphylococcus Aureus, Escherichia coli, and Candida Albicans in the wound culture, and the resident was receiving intravenous antibiotics. The facility's skin management policy required weekly skin assessments, which were not adhered to in this case, resulting in actual harm to the resident.
Medication Administration Errors Leading to 11.5% Error Rate
Penalty
Summary
The facility failed to ensure medication error rates were less than 5%, resulting in an 11.5% error rate. This was observed during medication administration for two residents. Resident #30, who has diagnoses including hypertensive heart disease and gastrointestinal hemorrhage, was prescribed Calcium Carbonate with Vitamin D but was only given Calcium 600 mg by RN #10. The nurse confirmed the error during an interview. Resident #75, with diagnoses such as acute kidney failure and type two diabetes mellitus, was supposed to receive Polysaccharide Iron Complex and Senna-S but was instead given Colace and other medications by LPN #15. The nurse admitted to not administering the correct medications as per the physician's orders. The facility's policy on medication administration was not followed, contributing to these errors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mason
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mcv Health Care Facilities, Inc | 0.6 mi | ★★★★★ | 2 | 0 |
| Chesterwood Atc | 2.4 mi | ★★★★★ | 0 | 0 |
| Mason Health Care Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Heritagespring Healthcare Center Of West Chester | 3.2 mi | ★★★★★ | 3 | 1 |
| Lodge Nursing & Rehab Center | 3.2 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.