Inspection·March 28, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 03/26/24 at 11:51 A.M. revealed Resident #32's lunch was served in a disposable white clamshell Styrofoam container with disposable cutlery. Interview on 03/27/24 at 8:28 A.M. with State Tested Nurse Aide (STNA) #93 revealed it was not standard practice for residents to be served meals on disposable dishware and with disposable cutlery. STNA #93 verified Resident #32 received all meals on disposable dishware and was did not know why. Observation on 03/27/24 at 8:04 A.M. of the breakfast service for Resident #32 revealed the resident was sitting up in a chair eating breakfast from his bedside table. The breakfast meal was served to Resident #32 in a disposable white clamshell Styrofoam container with disposable cutlery. The disposable white clamshell Styrofoam container remained on bedside table. Interview on 03/27/24 at 1:36 P.M. with the Director of Nursing (DON) verified Resident #32 was served meals on disposable containers with disposable cutlery. Further interview with the DON indicated she found the intervention inappropriate. 2. Observation on 03/25/24 at 11:49 A.M. of the memory care unit dining room revealed twelve residents were seated and eight resident meal trays had been served. Four residents (#9, #21, #30, and #51) had not received the lunch meal and were seated with residents who had begun eating. Resident #9 was observed to pick up a food item from Resident #46's meal tray whom she was seated with. Resident #25 completed the meal and left the dining room as tablemate (Resident #30) received the lunch meal. All residents received food by 12:12 P.M. Interview on 03/25/24 at 12:09 P.M. with Activities Staff #204 revealed there was a mix-up and staff were going to get the missed lunch meals. Activities Staff #204 verified residents seated at the same table had not been served at the same timeframe. Review of the policy titled, Resident's Rights, dated December 2020, verified each resident has a right to a dignified existence, self-determination, communication with and access to persons and services inside and outside the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365624 If continuation sheet Page 2 of 13 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 365624 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Perrysburg 28546 Starbright Blvd Perrysburg, OH 43551 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 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm Based on review of resident funds accounts, fund balance notification documents, medical record review, and staff interview, the facility failed to ensure notifications of funds in excess of the Medicaid limit were followed up with timely notification and assistance to lower the fund balance. This affected three residents (#03, #24 and #27) of five reviewed for personal funds. The facility census was 50. Residents Affected - Few Findings Include: 1. Review of Resident #03's personal funds account revealed a balance of $3,277.29 on 03/31/23, a balance of $3,349.38 on 06/30/23, a balance of $3,412.47 on 09/29/23, a balance of $3,502.56 on 12/29/23, and a balance of $3,529.60 on 03/26/24. Further review revealed the facility sent a document titled, Resident Fund Balance Notification, on 01/23/24 and 03/22/24 to the resident's representative indicating they were to notify the Social Worker within the next seven days to discuss ways to assure continuance of Medicaid benefits. There was no record of a discussion with the representative located in Resident #03's medical record. 2. Review of Resident #24's personal funds account revealed a balance of $2,263.62 on 03/31/23, a balance of $2,260.74 on 06/30/23, a balance of $2,029.51 on 09/29/23, a balance of $2,156.07 on 12/29/23, and a balance of $2,598.91 on 03/26/24. Further review revealed the facility sent a document titled, Resident Fund Balance Notification, on 05/19/23 and 05/22/24 to the resident's representative indicating they were to notify the Social Worker within the next seven days to discuss ways to assure continuance of Medicaid benefits. There was no record of a discussion with the representative located in Resident #24's medical record. 3. Review of Resident #27's personal funds account revealed a balance of $3,071.28 on 03/31/23, a balance of $6,141.34 on 06/30/23, a balance of $5,070.48 on 09/29/23, a balance of $7,195.48 on 12/29/23, and a balance of $6,016.62 on 03/26/24. Further review revealed the facility sent a document titled, Resident Fund Balance Notification, on 01/02/24 and 03/22/24 to the resident's representative indicating they were to notify the Social Worker within the next seven days to discuss ways to assure continuance of Medicaid benefits. There was no record of discussion with the representative located in Resident #27's medical record. Interview on 03/28/24 at 1:12 P.M. with Social Worker Designee (SWD) #195 revealed she was recently notified that Resident #24's account exceeded $2,000.00, but had not yet contacted Resident #24's family and/or representative about her account. Further interview revealed SWD #195 was not aware Resident #03's and Resident #27's accounts exceeded the Medicaid limit. SWD #195 understood residents covered under Medicaid, such as Resident #03, Resident #24, and Resident #27, were at risk of losing their benefits when their assets exceeded the Medicaid limit of $2,000.00. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365624 If continuation sheet Page 3 of 13 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 365624 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Perrysburg 28546 Starbright Blvd Perrysburg, OH 43551 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure resident wheelchairs were kept in a clean and sanitary manner. This affected three (#25, #32 and #43) of three residents reviewed for wheelchairs. The census was 50. Findings include: 1. Review of the medical record revealed Resident #25 was admitted on [DATE] with a re-admission date of 02/16/23. Diagnoses included multiple sclerosis, vascular dementia severity with agitation, type two diabetes mellitus with diabetic neuropathy, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and other abnormalities of gait and mobility. Review of the Minimum Data Set (MDS) assessment, dated 01/19/24, revealed Resident #25 was assessed with moderate cognitive impaired and used a wheelchair. Observation on 03/25/24 at 9:42 A.M. with Resident #25 revealed the resident was in his wheelchair and the wheelchair had a thick build-up of dirt and debris along the outside. Observation on 03/27/24 at 3:53 P.M. revealed Resident #25's wheelchair continued to have a buildup of dirt and debris on the outside of the wheelchair. 2. Review of the medical record review revealed Resident #32 was admitted on [DATE]. Diagnoses included unspecified dementia, unspecified osteoarthritis, muscle weakness, other abnormalities in gait and mobility, and difficulty walking. Review of the MDS assessment, dated 03/07/24, revealed the resident was assessed as severely cognitively impaired and used a wheelchair or scooter. 3. Review of the medical record revealed Resident #43 was admitted on [DATE]. Diagnoses included bipolar disorder, difficulty in walking, unsteadiness on feet, dementia in other diseases, and unilateral post-traumatic osteoarthritis of the first carpometacarpal joint. Review of the MDS assessment, dated 02/05/24, revealed the resident was severely cognitively impaired and utilized a wheelchair. Interview on 03/27/24 at 4:00 P.M. with Licensed Practical Nurse (LPN) #117 revealed resident's wheelchairs should be cleaned by night shift staff in the shower room. LPN #117 verified Resident #25's wheelchair was dirty. Observation on 03/27/24 at 4:01 P.M. of Resident #32's and Resident #43's wheelchairs revealed the residents were sitting in their wheelchairs and the outside of the wheelchair wheels had a heavy buildup of dirt and debris. Continued interview with LPN #117 verified Resident #32's and Resident #43's wheelchairs were dirty and were in need of being clean. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365624 If continuation sheet Page 4 of 13 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 365624 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Perrysburg 28546 Starbright Blvd Perrysburg, OH 43551 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 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a comprehensive assessment was completed timely after a significant change in a resident's status. This affected one (#47) of 14 residents reviewed for assessments. The facility census was 50. Residents Affected - Few Findings include: Review of the medical record for Resident #47 revealed an admission date of 08/03/23 with diagnoses of congestive heart failure and hemiplegia and hemiparesis affecting the left non-dominant side. Review of Resident #47's physician orders revealed an order dated 09/07/23 to admit Resident #47 to hospice with a diagnoses of diastolic heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a comprehensive assessment was completed due to a significant change in Resident #47's status. Interview on 03/27/24 at 4:05 P.M. with Regional Support Registered Nurse #90 confirmed Resident #47 was admitted to hospice on 09/07/23 and a significant change comprehensive MDS assessment was not completed until 10/11/23. Interview 03/28/24 at 12:34 P.M. with Regional Clinical #204 confirmed the significant change comprehensive MDS assessment should have been completed within 14 days of Resident #47's admission to hospice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365624 If continuation sheet Page 5 of 13 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 365624 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Perrysburg 28546 Starbright Blvd Perrysburg, OH 43551 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital documentation review, staff interview, and review of a facility policy, the facility failed to develop a care plan with appropriate interventions when a resident was readmitted to the facility with a new diagnosis following a hospitalization. This affected one resident (#42) of 14 residents reviewed for care plans. The facility census was 50. Findings include: Review of the medical record for Resident #42 revealed an admission date of 05/05/22. Diagnoses included chronic obstructive pulmonary disease, major depressive disorder, hypertension, heart failure, and dementia. On 02/20/24 a diagnoses was added to include a subdural hematoma (a collection of blood between the brain and its outermost cover) when the resident was re-admitted to the facility from a hospitalization. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was assessed with cognitive impairment and was dependent on staff for activities of daily living. Review of hospital documents between 02/17/24 and 02/20/24 revealed Resident #42 was admitted for pyelonephritis, hypotension, and a subdural hematoma in the frontal and high parietal region. A repeat computed tomography (CT) scan was completed on 02/18/24 and revealed a minimal increase in the subdural hematoma. Review of the hospital discharge record printed on 02/20/24 at 6:11 P.M. revealed Resident #42 was discharged in stable condition with orders to stop taking aspirin, have a basic metabolic panel (laboratory work) obtained around 02/27/24, have a CT scan completed by 03/08/24, and follow up with neurosurgery on 03/13/24 at 10:00 A.M. Review of the progress note dated 02/21/24 and timed 3:35 A.M. revealed Resident #42 returned to the facility at approximately 7:00 P.M. on 02/20/24 and was treated for an acute subdural hematoma, urinary tract infection, and pneumonia. Additional review of the medical record from 02/20/24 to 03/28/24 for Resident #42 revealed no care plan with interventions for monitoring a subdural hematoma was developed following Resident #42's readmission to the facility on [DATE]. Interview on 03/28/24 at 1:00 P.M. with Regional Clinical Director #204 verified the care plan for Resident #42 should have been updated to reflect a new diagnosis of a subdural hematoma on readmission and appropriate interventions for monitoring should have been implemented per the facility policy. Regional Clinical Director #204 stated staff knew the residents and completed assessments daily on each resident, however, the assessments are not always documented. Interview on 03/28/24 at 2:33 P.M. with the Medical Director (MD) stated he was aware of Resident #42's new diagnosis of a subdural hematoma and Resident #42 being followed by neurosurgery. The MD stated, at minimum, due to the subdural hematoma, Resident #42 should have neurological checks three times a day until cleared by neurosurgery. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365624 If continuation sheet Page 6 of 13 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 365624 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Perrysburg 28546 Starbright Blvd Perrysburg, OH 43551 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 0655 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Care Plans, dated 10/22, revealed overall care plans will address diagnoses, physician orders, medications, treatments, general care, devices and interventions, behaviors, and other needs specific to the resident. The care plan is generally updated as needed within seven business days of the time a change is identified or ordered. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365624 If continuation sheet Page 7 of 13 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 365624 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Perrysburg 28546 Starbright Blvd Perrysburg, OH 43551 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure laboratory tests were completed as ordered by the physician. This affected one (#42) of six residents reviewed for laboratory testing. The facility census was 50. Findings include: Review of the medical record for Resident #42 revealed an admission date of 05/05/22. Diagnoses included chronic obstructive pulmonary disease, major depressive disorder, hypertension, heart failure, and dementia A diagnosis of a subdural hematoma (a collection of blood between the brain and the outermost cover) was added on 02/20/24 when the resident was readmitted from a hospitalization. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was assessed with cognitive impairment and was dependent on staff for activities of daily living. Review of the hospital discharge record for continuation of care printed on 02/20/24 at 6:11 P.M. revealed Resident #42 was discharged back to the facility in stable condition with orders to stop taking aspirin and to have a basic metabolic panel (laboratory work) completed around 02/27/24. Review of the physician orders for Resident #42 revealed no basic metabolic panel was ordered to be completed. Review of the medical record for Resident #42 revealed no results for a basic metabolic panel. Review of the laboratory draw log revealed no basic metabolic panel was scheduled to be drawn for Resident #42. Interview on 03/28/24 at 1:31 P.M. with Licensed Practical Nurse (LPN) #113 verified the basic metabolic laboratory test was not completed as the order was not entered upon Resident #42's return to the facility after hospitalization. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365624 If continuation sheet Page 8 of 13 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 365624 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Perrysburg 28546 Starbright Blvd Perrysburg, OH 43551 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 0777 Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital documentation review, and staff interview, the facility failed to ensure diagnostic services were provided as ordered. This affected one resident (#42) of 14 residents reviewed for care and services. The facility census was 50. Residents Affected - Few Findings include: Review of the medical record for Resident #42 revealed an admission date of 05/05/22. Diagnoses included chronic obstructive pulmonary disease, major depressive disorder, hypertension, heart failure, and dementia. On 02/20/24 a diagnoses was added to include a subdural hematoma (a collection of blood between the brain and its outermost cover) following a readmission to the facility from a hospitalization. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was assessed with cognitive impairment and was dependent on staff for activities of daily living. Review of the progress notes dated 02/17/24 at 3:32 A.M. revealed Resident #42 was sweaty and difficult to arouse, so the physician was notified and orders were received to transport the resident to the hospital for further evaluation. Resident #42 left the faciity on [DATE] at 4:03 A.M. per emergency medical services. Further review of a progress note dated 02/17/24 at 9:13 A.M. revealed Resident #42 was admitted to the intensive care unit due to a brain bleed and urinary tract infection. Review of hospital documents between 02/17/24 and 02/20/24 revealed Resident #42 was admitted for pyelonephritis, hypotension, and a subdural hematoma in the frontal and high parietal region. A repeat computed tomography (CT) scan was completed on 02/18/24 and revealed a minimal increase in the subdural hematoma. Neurosurgery was consulted and no surgical intervention was required. Resident #42 was to follow-up with neurosurgery in three weeks. Review of the hospital discharge record printed on 02/20/24 at 6:11 P.M. revealed Resident #42 was discharged in stable condition with orders to stop taking aspirin, have a basic metabolic panel (laboratory work) obtained around 02/27/24, have a CT scan completed by 03/08/24, and follow up with neurosurgery on 03/13/24 at 10:00 A.M. Review of the progress note dated 02/21/24 and timed 3:35 A.M. revealed Resident #42 returned to the facility at approximately 7:00 P.M. on 02/20/24 and was treated for an acute subdural hematoma, urinary tract infection, and pneumonia. Additional review of the medical record from 02/20/24 to 03/28/24 for Resident #42 revealed no documentation of a repeat CT scan completed, and an order for a head CT scan to be completed on 04/01/24 which had been scheduled on 03/26/24 at 1:10 P.M. Review of the neurosurgery progress note dated 03/13/24 revealed Resident #42 presented for the follow up appointment of the recent hospitalization for altered mental status and subdural hematoma with a plan to review the repeat CT scan, but the repeat CT scan had not been completed. Further review of the assessment and plan of the visit revealed Resident #42 still needed the repeat CT scan to ensure resolution of the previous areas of bleeding, and an order and instructions were again provided (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365624 If continuation sheet Page 9 of 13 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 365624 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Perrysburg 28546 Starbright Blvd Perrysburg, OH 43551 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 0777 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to the facility. Instructions were to repeat the CT scan and to have Resident #42 return in about three weeks for follow-up. Interview on 03/27/24 at 3:41 P.M. with the Director of Nursing (DON) stated she was aware of Resident #42 needing a repeat CT scan after Resident #42 returned from the neurosurgery appointment on 03/13/24, and further verified the instructions on the continuation of care paperwork for the repeat CT scan were not followed. Interview on 03/27/24 at 4:30 P.M. with Regional Clinical Nurse #90 stated the facility nurse practitioner did not order a repeat CT scan when Resident #42 returned from the hospital on [DATE]. Interview on 03/28/24 at 8:25 A.M. with Nurse Practitioner (NP) #203 acknowledged Resident #42 had a subdural hematoma, was being followed by neurosurgery, and neurosurgery ordered a repeat head CT scan to check the status of the subdural hematoma. NP #203 stated the CT scan was ordered by the specialist, therefore she would not reorder it to ensure the results would be sent to neurosurgery. NP #203 would expect the facility to follow the continuation of care orders when a specialist was involved in the care of a resident. NP #203 stated questions regarding orders are usually clarified, and stated there were no questions nor was she asked for clarification of the repeat CT scan order. NP #203 further denied knowledge of the repeat CT scan for Resident #42 not being completed prior to the follow up neurosurgery appointment on 03/13/24. Interview on 03/28/24 at 1:31 P.M. with Licensed Practical Nurse (LPN) #113 verified the head CT scan was not completed for Resident #42 as the order was not entered upon Resident #42's return to the facility after hospitalization and should have been. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365624 If continuation sheet Page 10 of 13 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 365624 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Perrysburg 28546 Starbright Blvd Perrysburg, OH 43551 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff and resident interview, and facility policy review, the facility failed to maintain proper infection control practices when providing care and services. This affected four (#18, #26, #37, and #48) of 14 residents observed receiving care and services from staff. The facility census was 50. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 09/29/20 with diagnoses of hypertension, gastroesophageal reflux, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had intact cognition. Review of Resident #18's current physician orders upon entrance on 03/25/24 revealed an order for the antibiotic Augmentin every twelve hours from 03/04/24 to 03/11/24, and contact precautions for a urinary tract infection with extended spectrum beta lactamase (ESBL) and Escherichia coli (E-coli). Observation on 03/25/24 at 12:08 P.M. revealed as State Tested Nurse Aide (STNA) #144 exited Resident #18's room revealed, STNA #144 placed eye protection on top of the isolation bin outside the room, removed a blue isolation gown in the doorway of room, and rolled the gown into itself and held it in the left hand. STNA #144 continued to closed the door to the room with the right hand, used the right hand to pick up the eye protection, and placed them into left hand with gown. STNA #144 then proceeded down the hallway, approached the double doors to the secured unit, pushed buttons on the keypad to enter the secured unit, opened the left door with the right hand, entered the secured unit, and proceeded to the soiled utility room. STNA #144 then pressed buttons on the keypad of the soiled utility room, opened the door using the door handle, and entered placing the gown and eye protection in a covered trash bin. Interview with STNA #144 on 03/25/24 at 12:15 P.M. verified the gown was removed in the room at the door and the isolation gown and eye protection were carried out of Resident #18's room and disposed of in the soiled utility room away from Resident #18's room. STNA #144 stated this was done because Resident #18 did not have a receptacle for soiled personal protective equipment (PPE) in the room. STNA #144 verified two separate doors and two different keypads where touched in the process of disposing of the isolation gown and eye protection. 2. Review of the medical record for Resident #26 revealed an admission date of 11/14/23. Diagnoses included end stage renal disease with dependence on renal dialysis, type II diabetes mellitus, chronic congestive heart failure, hypertension, atrial fibrillation, morbid obesity, major depressive disorder, anxiety disorder, and vitamin D deficiency. On 03/08/24 Resident #26 was diagnosed with acute peritonitis and on 03/15/23 was diagnosed with methicillin resistant staphylococcus aureus (MRSA). Review of the comprehensive MDS assessment dated [DATE] revealed Resident #26 was cognitively intact. Review of the care plan dated 03/17/24 revealed Resident #26 was on antibiotic therapy for positive blood cultures. Interventions included for medications to be administered as ordered and contact (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365624 If continuation sheet Page 11 of 13 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 365624 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Perrysburg 28546 Starbright Blvd Perrysburg, OH 43551 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 0880 Level of Harm - Minimal harm or potential for actual harm precautions for MRSA. An additional care plan dated 03/25/24 revealed Resident #26 had MRSA at the dialysis port with a goal for the infection to resolve. Review of the physician order written on 03/15/24 revealed Resident #26 was placed on contact isolation for peritonitis and MRSA with precautions maintained throughout the shift. Residents Affected - Some Observation on 03/25/24 at 10:00 A.M. revealed Resident #26 had no isolation precautions in place. Resident #26 had no signage or available PPE for the ordered precautions and Resident #26's room door was open. Observation on 03/25/24 at 3:26 P.M. revealed a contact isolation sign on Resident #26's closed door and a white three drawer bin with gowns, gloves, and hand sanitizer was to the left of the door. Observation of medication administration on 03/26/24 from 7:22 A.M. to 7:31 A.M. revealed Licensed Practical Nurse (LPN) #148 preparing the medications for Resident #26. LPN #148 removed supplemental vitamin D and the stool softener Colace from the multiple use medication container. LPN #148 poured the medications from the multiple use container into the left hand, and then placed the pill into the medication cup sitting on top of the medication administration cart. LPN #148 continued to remove the blood thinner Xarelto, the pain medication Gabapentin, the diuretic Lasix, and the blood pressure medications Metoprolol and Ditropan from pill packages with each medication pushed with the right thumb from the top of the pill package and LPN #148 grabbed the medication with the thumb and first finger of the left hand before placing the medications into the medication cup. At 7:31 A.M., LPN #148 entered Resident #26's room, sat the medication cup of pills on the over bed table, and Resident #26 took the medications with a cup of water. Interview on 03/26/24 at 7:45 A.M. with LPN #148 verified each medication was touched with hands and administered to Resident #26 without proper hand sanitation. Interview on 03/26/24 at 10:30 A.M. with Regional Support Registered Nurse (RSRN) #90 verified Resident #26 had an order for contact precautions written on 03/15/24 that had not been implemented until 03/25/24. Interview with Resident #26 on 03/26/24 at 4:30 P.M. revealed isolation precautions were implemented on Monday, 03/25/24. Resident #26 further verified staff members had not been wearing gowns and gloves when entering the room to assist with care prior to 03/25/24. Review of facility policy titled, Infection Control Practices, revised 03/24, revealed isolation precautions will be used throughout the facility to prevent the spread of infection. Transmission based precautions will be employed for known or suspected infections for which the route if transmission/prevention is known. The transmission-based precautions categories include airborne, droplet, and contact. Isolation precautions may be instituted by a physician, infection preventionist, the director of nursing, assistant director of nursing, or by a supervisor and may be discontinued only with a physician order. Signs instructing what type of personal protective equipment must be worn before entering the room will be placed at the doorway of the resident's room. Contact precautions are necessary when an illness is transmitted by direct contact. Recommendations include gloves, gown, private room. Designated dedicated items such as blood pressure cuff, stethoscope, thermometer for use only on that residents. Limited resident movement from the room to essential purposes only. If the resident must be transported, ensure that precautions are maintained to minimize the risk of transmission to other residents and environmental surfaces. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365624 If continuation sheet Page 12 of 13 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 365624 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Perrysburg 28546 Starbright Blvd Perrysburg, OH 43551 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Review of the medical record for Resident #37 revealed an admission date of 09/23/24. Diagnoses included hypothyroidism, vitamin D deficiency, and type II diabetes mellitus. Observation of medication administration on 03/26/24 from 7:31 A.M. to 7:45 A.M. revealed LPN #148 prepared medications for Resident #37 including the supplement ascorbic acid, the pain medication aspirin, a multivitamin, and the supplement folic acid were removed from multiple use medication containers. With each medication, LPN #148 poured the medications from the multiple use container into the left hand, and then placed each pill into the medication cup sitting on top of the medication administration cart. Continued observation revealed more than one ascorbic acid tablet poured out of the container and LPN #148 used the lip of the pill container to scoop the extra tablet back into the bottle from her hand. LPN #148 removed the heart medication Coreg, the antidepressant Effexor, the anti-diabetic Januvia, the antiplatelet Plavix, and the psychotropic medication Rexulti from pill packages and each medication was pushed with the right thumb from the top of the pill package, grabbed by the thumb and first finger of the left hand, and placed into the medication cup. At 7:45 A.M. LPN #148 entered Resident #37's room, handed the medication cup of pills to Resident #37, and Resident #37 poured the cup of pills into his mouth taking a drink of water to swallow the medications. Interview on 03/26/24 at 7:45 A.M. with LPN #148 verified each of Resident #37's medications was touched with hands and administered to Resident #37 without proper hand sanitation. Interview on 03/26/24 at 7:48 A.M. with LPN #113 verified LPN #148 did not follow proper practices when administered medications to Resident #26 and Resident #37. Review of the facility policy titled, Administration and Documentation of Medications, dated 10/22, revealed every resident receives medications by a licensed nurse. Medication is prepared in the medication area of the nurses station or the medication cart. Following the general standards for medication administration, if there is a concern about the sterility or integrity of the drug, the drug should not be administered. 4. Review of the medical record for Resident #48 revealed an admission date of 11/29/23. Diagnoses included osteomyelitis, paraplegia, retention of urine, and urinary tract infections on 02/04/24 and 03/12/24. Review of the quarterly MDS assessment dated [DATE] revealed Resident #48 was cognitively intact, had a functional impairment to one upper extremity and both lower extremities, was dependent for toilet use, and had an indwelling suprapubic catheter. Observation on 03/26/24 at 2:25 P.M. revealed Resident #48's urinary catheter collection bag was hanging from the cross bar under the bed and was sitting directly on the floor. Interview on 03/26/24 at the time of the observation with Regional Support Registered Nurse #90 verified the urinary drainage bag was on the floor and should not be. Review of the facility policy titled, Insertion, Removal and Care of an Indwelling Foley Catheter, dated 04/21, revealed a sterile, continuously closed drainage system should be maintained. For the inpatient in the setting, position the bag hanger on the bed rail near the foot of the bed using the clip to secure the drainage tube to the sheet. Always keep the bag below the level of the bladder to prevent the backflow of urine and decrease the risk of infection. Do not leave the bag lying on the floor unless necessary due to patient positioning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365624 If continuation sheet Page 13 of 13