Inspection·August 10, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few roommate. Resident #2 struck his roommate in the face and caused his nose to bleed. There were no other injuries and Resident #2 was not struck or injured. Staff reported the other resident was in good spirits and not aggressive. No staff members witnessed the incident. Review of the incident log dated 05/10/23 to 08/10/23 revealed Resident #2 was documented under the Resident to resident altercation incidents section on 06/20/23. Review of the facility's SRI dated 06/21/23 and timed 11:51 A.M. and the corresponding investigation, revealed the incident was reported and investigated. The facility did not substantiate the allegation of physical abuse and stated it was believed Resident #3 was wandering and went into Resident #2's room, went on Resident #2's side of the room and too close to Resident #2, and Resident #2 became combative not knowing Resident #3 was wandering. Interview on 08/10/23 at 3:48 P.M. with the Administrator verified the incident with Resident #2 hitting Resident #3 causing Resident #3 to cry and have a bleeding nose. 2. Review of the medical record for Resident #1, revealed the resident was admitted to the facility on [DATE]. Diagnoses included depression, vascular dementia, anxiety, wandering, and dysphagia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/01/23, revealed Resident #1 was cognitively impaired with no exhibited behaviors. Review of Resident #1's weekly skin assessment dated [DATE], identified no new skin concerns. Review of Resident #1's nursing progress notes dated 07/31/23 and timed 9:55 A.M., revealed Licensed Practical Nurse (LPN) #225 noted dark purple/red bruising to both ears with a laceration behind the right ear, smaller bruises on face and head, and bruises to left back along rib cage. When asked what happened, the resident stated the guy next door came in and was fighting him. He stated it was at night the night before last. Three people spoke with the resident separately at various times and his recollection remained the same. The Administrator, physician, and guardian were updated. Review of the head-to-toe assessment dated [DATE], identified deep purple/red bruising and laceration behind right ear, left ear bruising, multiple small bruises across face and head, and left back, rib cage area bruises. Review of Resident #1's physician orders, identified an order dated 07/31/23 to monitor bruising to head and left post ribs every shift until resolved. Review of the incident log dated 05/10/23 to 08/10/23 revealed Resident #2 was documented under the Resident to resident altercation incidents section on 07/31/23. Review of the facility's SRI, dated 07/31/23 and timed 2:53 P.M., revealed LPN #225 noted dark purple/red bruising behind both of Resident #1's ears. Upon closer inspection, smaller bruises were on his face and head and laceration behind right ear. The resident asked if the nurse wanted to see his back, lifted up his shirt, and more bruises were on his left back. The resident stated the man next door (Resident #2) came in his room and they fought. Review of the facility's investigation, revealed the facility determined the allegation of physical abuse was not verified due to the residents having no prior incidents, and it was believed Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365740 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 365740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Clyde 700 Helen Street Clyde, OH 43410 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 0600 Level of Harm - Minimal harm or potential for actual harm #2 woke up in the middle of the night to use the shared bathroom and Resident #1's side of the door was open which alarmed Resident #2 and caused him to act out. Review of Resident #1's weekly skin assessment dated [DATE], revealed bruising continued to head and back. Residents Affected - Few Interviews on 08/10/23 from 8:35 A.M. to 12:00 P.M. with Licensed Practical Nurse (LPN) #617, State Tested Nurse Aide (STNA) #473, and STNA #482, revealed staff were informed that during the night that Resident #2 went into the room of Resident #1 and beat him up. Staff reported they were not present when the incident occurred. Interview on 08/10/23 at 3:48 P.M. with the Administrator verified the incident with Resident #2 hitting Resident #1 causing bruising on his face and head a laceration behind his right ear. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated October 2022, revealed residents had the right to be free from abuse. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This deficiency represents non-compliance investigated under Control Number OH00145376. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365740 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 365740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Clyde 700 Helen Street Clyde, OH 43410 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 review of the facility's Self-Reported Incidents (SRI), staff interview, medical record review, and review of the facility policy for abuse, the facility failed to timely report allegations of physical abuse of residents to the State Survey Agency, Ohio Department of Health (ODH). This affected two (Resident #1 and #3) of three residents reviewed for abuse. The facility census was 53. Findings include: 1. Closed record review for Resident #2 revealed an admission date of 03/07/22. Diagnoses included heart disease, dementia, schizoaffective disorder, anxiety, depression, and cognitive communication deficit. Review of Resident #2's nursing progress notes dated 06/20/23 and timed 10:24 A.M., revealed a loud smacking sound was heard by an state tested nursing aide (STNA). Resident #2 was standing over his roommate (Resident #3) and stated he went after me. The roommate (Resident #3) was sitting on the bed crying out and blood dripping from his nose. Review of Resident #3's medical record revealed an initial admission date of 05/01/15. Diagnoses included bipolar disorder, schizoaffective disorder, anxiety, depression, and cognitive communication deficit. Review of Resident #3's nursing progress notes, dated 06/20/23 and timed 1:35 P.M., revealed the nurse and STNA heard a loud smack and the resident was crying out. Resident #3 was sitting on his roommate's (Resident #2) bed and Resident #3's nose was bleeding. Resident #2 was standing over Resident #3 and was moved to his own bed. Review of the facility's SRI dated 06/21/23 and timed 11:51 A.M. and the corresponding investigation, revealed the incident was reported and investigated. Interview on 08/10/23 at 3:48 P.M. with the Administrator confirmed physical abuse was alleged on 06/20/23 at 10:24 A.M. and the facility did not initiate the SRI until 06/21/23 at 11:51 A.M. 2. Review of the medical record for Resident #1, revealed the resident was admitted to the facility on [DATE]. Diagnoses included depression, vascular dementia, anxiety, and wandering. Review of Resident #1's nursing progress notes dated 07/31/23 and timed 9:55 A.M., revealed Licensed Practical Nurse (LPN) #225 noted dark purple/red bruising to both ears with a laceration behind the right ear, smaller bruises on face and head, and bruises to left back along rib cage. When asked what happened, the resident stated the guy next door came in and was fighting him. He stated it was at night; the night before last. Review of the facility's SRI, dated 07/31/23 and timed 2:53 P.M., revealed LPN #225 noted dark purple/red bruising behind both of Resident #1's ears. Upon closer inspection, smaller bruises were on his face and head and laceration behind right ear. The resident asked if the nurse wanted to see his back, lifted up his shirt, and more bruises were on his left back. The resident stated the man next door (Resident #2) came in his room and they fought. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365740 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 365740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Clyde 700 Helen Street Clyde, OH 43410 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 08/10/23 at 3:48 P.M. with the Administrator confirmed physical abuse was alleged for Resident #1 on 07/31/23 at 9:55 A.M., and the facility did not initiate the SRI until 07/31/23 at 2:53 P.M. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated October 2022, revealed residents had the right to be free from abuse. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy also stated when abuse was alleged, the Administrator and/or his/her designee would notify the Ohio Department of Health (ODH) immediately, but no later than two hours after the allegation was made. This deficiency represents non-compliance investigated under Control Number OH00145376. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365740 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 365740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Clyde 700 Helen Street Clyde, OH 43410 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 medical record review, staff interview, review of the Self-Reported Incident (SRI), review of the facility investigation, and review of the facility policy for abuse, the facility failed to complete a thorough investigation related to an allegation of physical abuse to a resident. This affected one (#1) of three residents reviewed for abuse. The facility census was 53. Residents Affected - Few Findings include: Review of the medical record for Resident #1, revealed the resident was admitted to the facility on [DATE]. Diagnoses included depression, vascular dementia, anxiety, and wandering. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/01/23, revealed Resident #1 was cognitively impaired with no exhibited behaviors. Review of Resident #1's nursing progress notes dated 07/31/23 and timed 9:55 A.M., revealed Licensed Practical Nurse (LPN) #225 noted dark purple/red bruising to both ears with a laceration behind the right ear, smaller bruises on face and head, and bruises to left back along rib cage. When asked what happened, the resident stated the guy next door came in and was fighting him. He stated it was at night the night before last. Three people spoke with the resident separately at various times and his recollection remained the same. The head-to-toe assessment dated [DATE], identified deep purple/red bruising and laceration behind right ear, left ear bruising, multiple small bruises across face and head, and left back, rib cage area bruises. Review of the facility's SRI, dated 07/31/23, revealed LPN #225 noted dark purple/red bruising behind both of Resident #1's ears. Upon closer inspection, smaller bruises were on his face and head and laceration behind right ear. The resident asked if the nurse wanted to see his back, lifted up his shirt, and more bruises were on his left back. The resident stated the man next door (Resident #2) came in his room and they fought. Review of the facility investigation, revealed the facility determined the allegation of physical abuse was not verified due to the residents having no prior incidents, and it was believed Resident #2 woke up in the middle of the night to use the shared bathroom and Resident #1's side of the door was open which alarmed Resident #2 and caused him to act out. A written statement provided by LPN #225, revealed the resident reported the incident occurred on the night of 07/29/23 to 07/30/23. The investigative documentation contained no evidence the staff working the night of or the day or night following the alleged occurrence were interviewed. Interview on 08/10/23 at 12:17 P.M. with LPN #540, revealed LPN #540 was the nurse on duty the night of the alleged incident. LPN #540 confirmed she was never interviewed or asked to provide a statement regarding the alleged incident. Interview on 08/10/23 at 3:48 P.M. with the Administrator, verified interviews were not documented for all staff who were working the night of, or the day or night after the alleged incident. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated October 2022, revealed residents had the right to be free from abuse. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy further stated the person (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365740 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 365740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Clyde 700 Helen Street Clyde, OH 43410 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 Level of Harm - Minimal harm or potential for actual harm investigating an incident would generally interview all witnesses including those who came in close contact with the resident the day of the incident and employees who worked closely with the alleged victim the day of the incident. This deficiency represents non-compliance investigated under Control Number OH00145376. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365740 If continuation sheet Page 7 of 7