Inspection·December 10, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to report an allegation of an injury of unknown origin to the State Agency. This affected one (#31) of three residents reviewed for abuse. The facility census was 55.Review of the medical record for Resident #31 revealed an admission date of 03/27/25 with diagnoses including but not limited to anoxic brain damage, gastrostomy status, tracheostomy status, anxiety, cognitive communication deficit, and dysphagia.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was rarely/never understood and had severe cognitive impairment. The resident was dependent on staff for all activities of daily living.Review of the care plan dated 11/10/25 revealed the resident had the potential/actual impairment to skin integrity. Interventions included avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces.Review of the skin evaluation dated 10/25/25 marked incomplete, revealed multiple scratches to left arm. Incident report opened in error.Review of progress notes revealed no documentation regarding any scratches to left arm.Review of physician orders for October 2025 revealed no orders for scratches to left arm.Review of the facility's Self-Reported Incidents (SRI) revealed no SRI was completed for this incident. Interview on 12/10/25 at 2:07 P.M. with the Director of Nursing (DON) revealed he did not strike out the skin evaluation dated 10/25/25. The DON stated two events were opened on a Saturday and he only struck out one of them. DON verified they could not locate any nurse's notes or other documentation to support where the scratches came from or that the resident had scratches.Interview on 12/10/25 at 2:11 P.M. with Registered Nurse (RN #142) revealed that they were called into the resident's room and assessed the scratches to the residents left arm. RN #142 verified they did not put in an order for treatment to the scratches. RN #142 stated they completed a Risk Management and notified the family who already knew about them. RN #142 stated they did not know how the scratches happened so they did not fill out the predisposing factors on the risk.Interview on 12/10/25 at 2:18 P.M. with DON verified Resident #31's scratches were not investigated as to how they obtained them. DON verified it would be an injury of unknown origin if there was no supporting documentation as to where they came from and should have been investigated. Review of policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation dated 07/01/25 revealed all incidents and allegations of abuse, neglect, exploitation, mistreatment and misappropriation of resident/patient property and all injuries of unknown source must be reported immediately to the Administrator or designee. Injury of unknown source is an injury when all the following are met: the source of the injury was not observed by any person, the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. Once the Administrator and Department of Health are notified, an investigation of the allegation violation will be conducted.This deficiency represents non-compliance investigated under Complaint 2655109. Event ID: Facility ID: 365624 If continuation sheet Page 2 of 3 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 12/10/2025 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to investigate a injury of unknown origin. This affected one (#31) of three residents reviewed for abuse. The facility census was 55.Findings include:Review of the medical record for Resident #31 revealed an admission date of 03/27/25 with diagnoses including but not limited to anoxic brain damage, gastrostomy status, tracheostomy status, anxiety, cognitive communication deficit, and dysphagia.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was rarely/never understood and had severe cognitive impairment. The resident was dependent on staff for all activities of daily living.Review of the care plan dated 11/10/25 revealed the resident had the potential/actual impairment to skin integrity. Interventions included avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces.Review of the skin evaluation dated 10/25/25 marked incomplete, revealed multiple scratches to left arm. Incident report opened in error.Review of progress notes revealed no documentation regarding any scratches to left arm.Review of physician orders for October 2025 revealed no orders for scratches to left arm.Interview on 12/10/25 at 2:07 P.M. with the Director of Nursing (DON) revealed he did not strike out the skin evaluation dated 10/25/25. The DON stated two events were opened on a Saturday and he only struck out one of them. DON verified they could not locate any nurse's notes or other documentation to support where the scratches came from or that the resident had scratches.Interview on 12/10/25 at 2:11 P.M. with Registered Nurse (RN #142) revealed that they were called into the resident's room and assessed the scratches to the residents left arm. RN #142 verified they did not put in an order for treatment to the scratches. RN #142 stated they completed a Risk Management and notified the family who already knew about them. RN #142 stated they did not know how the scratches happened so they did not fill out the predisposing factors on the risk.Interview on 12/10/25 at 2:18 P.M. with DON verified Resident #31's scratches were not investigated as to how they obtained them. DON verified it would be an injury of unknown origin if there was no supporting documentation as to where they came from and should have been investigated.Review of policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation dated 07/01/25 revealed all incidents and allegations of abuse, neglect, exploitation, mistreatment and misappropriation of resident/patient property and all injuries of unknown source must be reported immediately to the Administrator or designee. Injury of unknown source is an injury when all the following are met: the source of the injury was not observed by any person, the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. Once the Administrator and Department of Health are notified, an investigation of the allegation violation will be conducted.This deficiency represents non-compliance investigated under Complaint 2655109. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365624 If continuation sheet Page 3 of 3