Majestic Care: Nurse Touched Pills with Bare Hands - OH
Inspectors observed LPN #336 on August 14 removing 13 different medications from pill cards for Resident #139 without gloves, physically touching each pill including aspirin, heart medications, and diabetes drugs. The nurse then administered the contaminated medications to the resident.
After giving the medications, the nurse washed her hands, put on gloves, and tested the resident's blood sugar with a glucometer. She placed the device back in its case, removed her gloves, washed her hands again, then picked up the glucometer case with her bare hands and put it in the medication cart.
The same contamination pattern repeated with Resident #140. Inspectors watched the nurse handle 12 medications with her bare hands, including antidepressants, blood pressure drugs, and pain medications. She touched each pill directly while removing them from pill cards.
When confronted about her practices, LPN #336 admitted she touched each pill she distributed. She also confirmed she did not clean the glucometer between residents, despite knowing facility policy required sanitizing the device with a wipe after each use.
The violations affected residents with serious medical conditions requiring careful medication management. Resident #139 had been admitted in April with diabetes, heart disease, chronic kidney disease, depression, and anxiety. The resident required 13 daily medications plus blood sugar monitoring.
Resident #140, admitted in April with type 2 diabetes and diabetic neuropathy, also suffered from high blood pressure, chronic kidney disease, depression, anxiety, chronic pain, anemia, and shoulder arthritis. This resident needed 12 different medications daily.
Both residents' complex medical needs made them particularly vulnerable to infections that could result from contaminated medications or unsterilized medical equipment.
The nurse's bare-hand contact with medications violated basic infection control protocols designed to prevent cross-contamination between residents. Touching pills directly can transfer bacteria, viruses, and other pathogens from the nurse's hands to medications that residents then consume.
The failure to sanitize the glucometer between residents created additional infection risks. Blood sugar testing devices can harbor bloodborne pathogens when not properly cleaned, potentially transmitting serious infections like hepatitis or HIV between patients.
Federal inspectors documented the violations during a complaint investigation numbered 1359585. The inspection occurred September 4, following the August observations of unsafe medication practices.
The nurse's admission that she knew proper glucometer cleaning procedures but chose not to follow them suggests willful disregard for resident safety protocols. Her acknowledgment that facility policy required sanitizing wipes between each resident use makes the violations more serious.
Majestic Care of Cedar Village operates at 5467 Cedar Village Drive in Mason. The facility must submit a correction plan addressing how it will ensure nurses follow proper medication handling and equipment sanitization procedures.
The violations represent a breakdown in basic nursing practices that put vulnerable elderly residents at unnecessary risk of infection and medication contamination. Both residents required extensive daily medication regimens for multiple chronic conditions, making safe administration practices essential to their health and wellbeing.
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 19, 2026 · Our methodology
MAJESTIC CARE OF CEDAR VILLAGE. in MASON, OH was cited for violations during a health inspection on September 4, 2025.
The nurse then administered the contaminated medications to the resident.
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.