Majestic Care of Cedar Village: Medication Failures - OH
The medication failures at Majestic Care of Cedar Village affected a resident with multiple serious conditions including congestive heart failure, chronic kidney disease, and hypothyroidism. The resident's doctor had ordered a specific combination vitamin containing folic acid, vitamin B6, and vitamin B12 in precise doses twice daily starting July 12, 2024.
Staff signed medication administration records showing they gave the 5 p.m. dose every day in July 2025. They marked the morning dose as given on only five days that month. In August, the pattern continued with staff signing for the evening dose daily while missing the morning dose on 14 of the first 17 days.
Licensed Practical Nurse #238 explained the problem during an August 18 interview with inspectors. The facility didn't have the prescribed medication available, she said. The over-the-counter vitamins on hand "did not have the correct amounts of vitamins and she did not administer it."
The nurse couldn't recall whether anyone notified the doctor or pharmacy about the missing medication.
Pharmacist #153 confirmed the facility's account. The pharmacy "did not supply the facility with folic acid, vitamin B6, vitamin B12, 4-50-2 milligrams tablet" as prescribed, the pharmacist told inspectors.
Director of Nursing verified that staff failed to administer the medication as ordered. She revealed a key detail about the timing: the facility had switched pharmacies on July 1, 2025, the same month the medication problems began.
Nobody documented any communication with the physician about the unavailable medication. No internal records showed staff tried to resolve the supply problem or notify the pharmacy about refill needs.
The director of nursing made a troubling admission about the medication records. She "can not confirm what the medication was that the facility staff was administering as the prescribed formula was not sent from the pharmacy."
This meant staff were signing medication records for doses they knew they weren't giving, or were giving something other than what the doctor prescribed without documenting what they actually administered.
The resident affected by these failures had been admitted with multiple conditions requiring careful nutritional support. A July 2024 care plan identified "potential nutritional risk" related to the resident's congestive heart failure, lung disease, hypothyroidism, anemia, and abnormal laboratory results.
The plan specifically called for "medications as ordered" and laboratory tests to monitor the resident's condition. The prescribed vitamin combination addresses common deficiencies in patients with these conditions, particularly those affecting blood formation and metabolism.
Federal regulations require nursing homes to provide pharmaceutical services to meet each resident's needs and ensure medications are available and administered according to physician orders. The facility's 142 residents depend on staff to manage their complex medication regimens accurately.
The medication administration records painted a clear picture of systematic failure. In July alone, the resident missed the prescribed morning dose on 26 of 31 days. Staff consistently signed for the evening dose while skipping the morning dose, suggesting they knew about the twice-daily requirement but couldn't fulfill it.
The August pattern showed no improvement despite the ongoing problem. Missing morning doses continued through at least August 17, when inspectors conducted their interviews.
The pharmacy switch in July appeared to trigger the medication shortage, but the facility's response revealed deeper problems with communication and oversight. No systems caught the missing medication. No protocols ensured physician notification when prescribed drugs weren't available.
Staff continued signing medication records as if doses were given, creating false documentation that could mislead doctors monitoring the resident's condition and laboratory results.
The director of nursing's inability to confirm what medication staff actually gave raises additional concerns about medication safety and accurate record-keeping at the 142-bed facility.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. The investigation stemmed from a complaint filed with state regulators.
The resident with multiple serious health conditions continued to go without the prescribed vitamin combination while staff maintained the fiction in medical records that proper doses were being administered twice daily.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Majestic Care of Cedar Village. from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
MAJESTIC CARE OF CEDAR VILLAGE. in MASON, OH was cited for violations during a health inspection on September 4, 2025.
Staff signed medication administration records showing they gave the 5 p.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.