Inspection·October 23, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure falls were thoroughly investigated to determine a root cause, documented in the medical record, and immediate interventions were put in place which were appropriate. This affected three (#5, #13, and #54) of three residents reviewed for falls. The facility census was 51.Findings include:1. Review of the medical record for Resident #5 revealed an admission date of 12/08/23 with diagnoses including but not limited to dementia mild with agitation, syncope and collapse, muscle weakness, difficulty walking, and cognitive communication deficit.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had severe cognitive impairment and required supervision or touching assistance for bed mobility, transfers, and ambulation.Review of the care plan dated 09/03/25 revealed Resident #5 was at risk for falls related to dementia, side effects of medications, diagnosis of syncope and collapse, muscle weakness, and cognitive communication deficit. Interventions included to encourage call light use, encourage use of a walker, frequent checks, instruction on safety measures for a new environment, medication review for increased agitation in the afternoon, monitor closely while in the bathroom, provide activities for distraction, antibiotic therapy, and be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed, the resident needed prompt response to all requests for assistance, maintain the bed in low position, collect urinalysis for culture and sensitivity, encourage to use a wheelchair, a floor mat, non-skid socks (09/04/25), provide a gait belt when walking with staff, identification that the resident puts self on the floor (10/06/25), and therapy evaluation.Review of Resident #5's fall follow-up note dated 09/05/25 revealed the interdisciplinary team (IDT) met and discussed the fall that occurred on 09/04/25. Resident #5 was found on the floor and was unable to explain what happened. The resident was assessed and no injuries were noted. The resident was assisted off the floor. The immediate intervention was to don non-skid socks on the feet. Neurological checks were initiated and the physician and family were notified of fall. The current care plan was reviewed and noted that appropriate interventions were in place. A new intervention implemented was to ensure the resident had non-skid socks on and the care plan was updated.Review of an alert note dated 09/27/25 revealed Resident #5 fell in the dining room. The resident was noted to be sitting on his bottom. There were no injuries noted and range of motion was within normal limits in all extremities. The resident denied any pain or discomfort and all parties were notified. Further review revealed no documentation of an immediate intervention was put in to place.Review of a fall follow-up note dated 09/29/25 revealed the IDT met and discussed Resident #5 fall that occurred on 09/27/25. The resident was found on the floor in the dining room and the resident was unable to explain what occurred due to diagnoses. Resident #5 was assessed and no injuries were noted from the fall. An immediate intervention was to place non-skid socks on the resident. Neurological checks were initiated and the physician and Power of Attorney (POA) were notified. The current care plan was reviewed and a new intervention for therapy to assess the resident was added.Review of a general progress note dated 09/30/25 revealed Resident #5 was found lying down on the floor face up in his room. There were no injuries, pain, or discomfort noted and neurological checks were initiated. The resident's Guardian, physician, and unit manager were notified. There was no documentation of an immediate intervention put into place.Review of a general progress note dated 10/04/25 revealed Resident #5 was found sitting on the floor in the activity room. The resident voiced no complaints of pain or discomfort. It was noted the resident sustained a skin tear to the right wrist. A new dressing was applied to the right wrist, neurological checks were initiated, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365624 If continuation sheet Page 2 of 7 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 10/23/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the Director of Nursing (DON), unit manager, physician, and Guardian notified. There was no documentation of an immediate intervention put into place per the note.Review of a fall follow-up note dated 10/06/25 revealed the IDT met and discussed Resident #5's fall that occurred on 10/04/25. The resident was found on the floor in the activity room and was unable to say what happened. Resident #5 was assessed and noted to have a skin tear to the right wrist. The resident was assisted off the floor and taken to his room. An immediate intervention was to place non-skid socks on the resident's feet. Neurological checks were initiated and the physician and POA were notified. The current care plan was reviewed and a new intervention to encourage the resident to use a wheelchair was implemented.Review of all fall follow-up progress notes from 09/04/25 through 10/13/25 for Resident #5 revealed no root cause analysis or thorough investigation of the falls.2. Review of the medical record for Resident #13 revealed an admission date of 01/21/25 with diagnoses including but not limited to dementia, anxiety disorder, and neurocognitive disorders with Lewy bodies.Review of the MDS assessment dated [DATE] revealed Resident #13 had severe cognitive impairment and required substantial/maximal assistance for transfers.Review of the care plan dated 01/22/25 revealed Resident #13 was at risk for injury related to falls. Interventions included to assess medications for side effects, collect urinalysis and culture and sensitivity, encourage the resident to be in the common area while awake, encourage the resident to wear shoes during waking hours, frequent rounding, label the walker, maintain a low bed, offer the resident the bathroom throughout the shift to decrease incontinence, provide activities for distraction, provide daily activities of daily living as soon as the resident wakes up, rearrange the bed for safe parameters, remind the resident to use a walker, remind staff to use a walker during showers, therapy to evaluate, and use gait belt in shower room.Further review of the care plan revealed Resident #13 was at risk for falls or fall related injury related to impaired cognition, poor safety awareness, recurrent falls, high risk medications, impaired mobility, and history of falls. Interventions included for staff to ensure a walker was within reach at all times/redirect resident to go get a walker when she forgets it, encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, encourage and assist the resident to wear appropriate non-skid footwear, ensure assistive devices are working properly, ensure the bed was made when the resident was up, keep the call light and frequently used personal items within reach, keep pathways clear and well lit, medication review, provide a pillow for positioning, allow the resident periods of rest when becoming combative with care, therapy evaluation, assist with toileting, and assist with transfers.Review of Resident #13's general progress notes and incident notes revealed no nursing documentation for the falls the resident sustained on 05/01/25 and 05/26/25.Review of Resident #13's fall follow-up notes revealed none were completed for the falls occurring on 05/23/25 and 07/06/25.Review of Resident #13's fall follow-up notes from 04/23/25 through 08/25/25 revealed no root cause analysis or complete and thorough investigations were completed.3. Review of the medical record for Resident #54 revealed an admission date of 09/11/25 and discharge date of 10/13/25. Diagnoses included but were not limited to cervical disk disorder at C5-C6 and C6-C7 levels with radiculopathy, cervical disc displacement at C4-C5 and C5-C6 levels, and kyphosis cervical region.Review of the MDS assessment dated [DATE] revealed Resident #54 was cognitively intact and required partial/moderate assistance for transfers, supervision or touching assistance for ambulation, and was independent in the wheelchair.Review of Resident #54's fall risk assessments dated 09/11/25, 09/22/25, and 10/02/25 revealed the resident was at high risk of falling. Review of the care plan dated 09/11/25 revealed Resident #54 was at risk for falls or fall related injury. Interventions included non-skid material to the wheelchair and to send to the emergency room for evaluation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365624 If continuation sheet Page 3 of 7 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 10/23/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few due to weakness.Review of a fall follow-up note dated 09/22/25 revealed the IDT met and discussed Resident #54's fall that occurred on 09/20/25. The resident was in the bathroom and while attempting to get out of the wheelchair the resident slid to the floor. The resident was assessed and it was noted there were no injuries related to the fall. Resident #54 was assisted off of the floor. An immediate intervention was implemented to educate the resident to use the call light for assistance. Neurological checks were initiated and the physician and the resident's family were notified. Resident #54's current care plan was reviewed and a new intervention for non-skid material to placed on wheelchair seat was initiated.Review of a general progress note dated 09/22/25 revealed the nurse was called into Resident #54's room via the nurse aide due to how weak the resident was. The nurse entered the resident's room and the the resident request to be sent to the emergency room. Laboratory values (labs) were drawn and lab results were pending. The resident's wife was notified about the change in condition.Review of a fall follow-up note dated 09/23/25 revealed the IDT met and discussed Resident #54's fall that occurred on 09/22/25. The resident was ambulating back to bed from the bathroom when his leg went weak and he fell to the floor. The resident was assessed and it was noted there were no injuries related to the fall. The resident was assisted off the floor and assisted back to bed. An immediate intervention was to ensure the call light was in reach of the resident. Neurological checks were initiated and the physician and family were notified. Resident #54 continued to complain about his leg feeling weak and requested to go to the emergency room for evaluation. The care plan was updated and there was no documentation of an intervention was put into place for this fall.Interview on 10/23/25 at 1:45 P.M. with the Administrator revealed the IDT meets to discuss falls during risk management and includes going to the resident's rooms to assess the situation following fall incidents. The Administrator stated the nurses are to enter risk management into the computer after a fall.Interview on 10/23/25 at 2:19 P.M. with the Director of Nursing (DON) verified there was no evidence of an immediate intervention for Resident #5 following the resident's falls on 09/27/25 and 09/30/25. The DON also confirmed duplicate interventions (non-skid socks) were implemented following two separate falls when the intervention should have already been in place from the previous fall, and there was no evidence the facility completed throughout investigations to determine root causes for each of Resident #5's falls between 09/04/25 and 10/13/25. Continued interview with the DON verified Resident #13's medical record lacked documentation for falls on 05/01/25 and 05/26/25, no fall follow-up documentation was completed for falls on 05/23/25 and 07/06/25, and no thorough investigations or root causes were determined for each of Resident #13's falls between 04/23/25 and 08/25/25. The DON also confirmed there was no documentation of an intervention implemented following Resident #54's fall on 09/22/25 to prevent future falls.Review of policy titled, Incidents, Accidents and Supervision, dated 01/02/24, revealed the purpose of incident reporting can include assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. Conducting root cause analysis to ascertain causative/contributing factors as part of the Quality Assurance Performance Improvement (QAPI) to avoid further occurrences. The following incidents/accidents require an incident/accident report but are not limited to falls. In the event of an unwitnessed fall of a non-interviewable resident or head injury for any resident, the nurse will initiate neurological checks. The nurse will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information. Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-up interventions.Review of policy titled, Fall Prevention, dated 01/02/24, revealed when any resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365624 If continuation sheet Page 4 of 7 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 10/23/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm experiences a fall, the facility will assess the resident, complete a post-fall assessment, complete an incident report, notify the physician and family, review the resident's care plan and update as indicated, document all assessments and actions, and obtain witness statements in the case of injury.This deficiency represents non-compliance investigated under Complaint Number 2630192. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365624 If continuation sheet Page 5 of 7 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 10/23/2025 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, review of meal tickets, resident and staff interview, and policy review, the facility failed to ensure nutritional assessments were completed timely to determine dietary preferences and failed to ensure food preferences were honored. This affected two (#32 and #54) of four residents reviewed for nutrition. The facility census was 51.Findings include:1. Review of the medical record for Resident #32 revealed an admission date of 02/27/25 with diagnoses including but not limited to congestive heart failure, Parkinsonism, type two diabetes mellitus, weakness, hypertension, and malignant neoplasm of the prostate.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had moderate cognitive impairment.Review of a care plan dated 02/27/25 revealed Resident #32 presented with a potential nutritional risk related to a therapeutic diet and diabetes with interventions included to honor food/fluid preferences, and provide and serve diet as ordered. There was no specified intervention indicating the resident requested no pork or beef. Review of a nutrition interview document dated 03/04/25 revealed Resident #32 liked chicken and fish and dislikes or avoids pork and beef.Review of Resident #32's current physician orders revealed a diet order for a regular diet with thin liquids and no mention of the resident requesting no pork or beef.Review of a nutrition/dietary note dated 03/05/25 revealed the dietician met with Resident #32 related to the resident being a new admission. The resident indicated he has a good appetite and was eating well at the facility with no issues. The resident also identified he liked chicken and fish. Further review revealed the resident's current diet order was a regular diet, regular texture, and thin liquids, with good oral intakes. Review of a meal ticket for Resident #32 dated 10/23/25 revealed an indication for no pork and beef.Interview on 10/22/25 at 11:29 A.M. with Resident #32 stated he does not want any beef or pork because it messes with his stomach. Resident #32 stated he preferred chicken and fish and verified he had received beef and pork on his tray on occasion. Observation on 10/22/25 at 12:00 P.M. of Resident #32 in the family room on the 200 hall revealed the resident had beef brisket, mashed potatoes, carrots, and a corn muffin on his plate. Interview on 10/22/25 at 12:02 P.M. with Unit Manager (UM) #200 verified Resident #32 had beef brisket, mashed potatoes, carrots, and corn muffin on his plate at lunch.2. Review of the medical record for Resident #54 revealed an admission date of 09/11/25 and discharge date of 10/13/25. Diagnoses included but were not limited to kidney transplant status, end stage renal disease, gastroesophageal reflux disease, anemia, and diabetes.Review of the MDS assessment dated [DATE] revealed Resident #54 was cognitively intact.Review of a nutrition/dietary note dated 09/17/25 revealed the dietician met with Resident #54 on that date and determined the resident's current diet order was a two gram sodium diet, with regular texture, thin liquids, and no pork. Resident #54 reiterated immediately he did not want any pork with his meals. Resident #54 also requested a controlled carbohydrate diet.Interview on 10/22/25 at 9:15 A.M. via telephone with Resident #54 revealed he did not want pork on his trays due to religious reasons and he would get pork on his tray. Resident #54 stated he would have send the meal trays it back to get something else. Resident #54 stated it never got completely fixed and he would still get pork on his tray on occasion after the dietician was made aware.Interview on 10/23/25 at 11:47 A.M. with Dietary [NAME] (DC) #256 stated she had been doing tray line for so long it was routine to her so she did not look at the meal tickets thoroughly. DC #256 stated she just glanced at the tickets. DC #256 stated she made cheat sheets on the rack above the tray line for reference and for new staff to help assist them. Observation of the cheat sheets, during interview with DC #256, confirmed Resident #32's sheet revealed to serve no pork and had no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365624 If continuation sheet Page 6 of 7 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 10/23/2025 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete mention of not serving beef.Interview on 10/23/25 at 1:45 P.M. with the Administrator revealed dietary preferences are put into the meal suite and are sent to the kitchen. The Administrator stated when she interviewed Resident #32 he verbally told her he did not like pork and did not mention not liking beef. The Administrator verified it was not documented anywhere and his meal tickets contained the notation for no pork or beef. The Administrator verified no nutritional interview was completed for Resident #54 upon admission to determine food preferences. The Administrator stated sometimes the residents think they are getting pork but it was not pork. For example, they served turkey sausage on 10/22/25 and the residents thought it was pork sausage.Review of the policy titled, Nutrition Assessment, dated 08/01/25, revealed each resident/patient will be interviewed within 72 hours of admission to determine food and meal preferences as well as to assess nutrition status and factors that may put the resident/patient at risk for altered nutrition. A registered dietician will assess the nutritional status of each resident/patient at a minimum at time of admission, with significant change in condition, and annually. Food allergies/intolerances will be confirmed and entered into the electronic medical record. The resident's/patient's nutrition care plan will be updated with each MDS assessment and as needs/interventions change.This deficiency represents non-compliance investigated under Complaint Number 2630192. Event ID: Facility ID: 365624 If continuation sheet Page 7 of 7