Inspection·March 7, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to ensure the physician was notified when blood glucose levels were outside of established parameters as ordered. This affected one (#36) of three residents reviewed for insulin. The facility census was 65. Findings include: Review of the medical record revealed Resident #36 was admitted on [DATE]. Diagnoses included end stage renal disease, type two diabetes mellitus with diabetic nephropathy and polyneuropathy, chronic diastolic (congestive) heart failure, muscle weakness, difficulty walking, delirium due to known physiological condition, essential hypertension, alcohol abuse, and major depressive disorder recurrent severe with psychotic symptoms. Review of the Minimum Data Set (MDS) assessment, dated 02/21/24, revealed Resident #36 was cognitively intact. Review of Resident #36's physician orders, dated 02/03/24 through 02/08/24, revealed an order for Novolog insulin to inject as per sliding scale subcutaneously before meals. Further review of the order revealed for blood sugars between 401 milligrams per deciliter (mg/dL) and 500 mg/dL, staff were instructed to provide 10 units of Novolog and notify the physician. Review of Resident #36's physician order, dated 02/22/24, revealed an order to check blood sugar every night at bedtime and to notify the physician if below 60 mg/dL or above 400 mg/dL. Review of the February 2024 medication administration record (MAR) revealed Resident #36 had a blood glucose level of 443 mg/dL at dinner time on 02/03/24, a blood glucose level of 493 mg/dL on at night time on 02/22/24, and a blood glucose level of 408 mg/dL at night time on 02/28/24. There was no documentation any of the three blood glucose levels above 400 mg/dL were notified to the physician as ordered. Review of Resident #36's nursing progress noted from February 2024 revealed no documentation of physician notification for blood glucose levels above 400 mg/dL on 02/03/24, 02/22/24, and 02/28/24. Interview on 03/06/24 at approximately 3:15 P.M. with Registered Nurse (RN) [NAME] President (VP) of Clinical #406, with review of Resident #36's February MAR and progress notes, verified there was no notification to the physician when Resident #36's blood glucose levels were above 400 mg/dL on 02/03/24, 02/22/24, and 02/28/24. Interview on 03/07/24 at 2:10 P.M. with Assistant Director of Nursing (ADON) #359 revealed the nurses on duty reported the physician notification was made and physicians were aware of Resident #36's unstable blood glucose levels, but could not provide evidence to verify the physician was notified for Resident #36's blood glucose levels when they were above 400 mg/dL on 02/03/24, 02/22/24, and 02/28/24. Review of a policy titled, Diabetes-Clinical Protocol, dated May 2023, verified the physician will establish desired parameters for monitoring and reporting information related to diabetes or blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366039 If continuation sheet Page 2 of 6 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 366039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Point Place 6101 N Summit St Toledo, OH 43611 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 0580 sugar management. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366039 If continuation sheet Page 3 of 6 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 366039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Point Place 6101 N Summit St Toledo, OH 43611 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure orders to discontinue psychotropic medications were followed according to the physician order. This affected one resident (#44) of five residents reviewed for unnecessary medications. The facility census was 65. Findings Include: Review of Resident #44's medical record revealed an admission date of 12/01/22. Diagnoses included neurocognitive disorder with lewy bodies (dementia), schizoaffective disorder, chronic kidney disease, cognitive communication deficit, muscle weakness, chronic pain, depressive episodes, and anxiety disorder. Review of Resident #44's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three indicating Resident #44 was severely cognitively impaired. Resident #44 was dependent on staff for activities of daily living including toilet use, bathing, dressing, transfer, and eating. Resident #44 displayed no behaviors at the time of the review. Review of Resident #44's care plan revised 02/26/24 revealed supports and interventions for self-care deficit, limited mobility, impaired cognitive function, hallucinations, behavioral concerns, and risk for pain. Review of Resident #44's physician orders revealed an order dated 02/02/24 for the antipsychotic Risperdal one (1) milligram (mg) to give 0.5 tablets at bed time for physical aggression, visual hallucinations; and give one tablet in the morning for visual hallucinations and physical aggression. Review of Resident #44's monthly pharmacy reviews revealed on 01/21/24 the pharmacist recommended considering a dose reductions of one drug, either Risperdal 0.5 mg at night or the mood stabilizer valproic acid 125 mg in the morning. The physician reviewed the recommendation on 02/06/24 and agreed to consider a dose reduction for Resident #44's Risperdal. The physician order was to decrease Resident #44's Risperdal to every other day for one week and then discontinue. Further review of Resident #44's physician orders revealed an order dated 02/06/24 and discontinued 02/29/24 for Risperdal 1 mg give one tablet in the morning every other day for schizophrenia every other day for one week and then discontinue. Review of Resident #44's February 2024 medication administration record (MAR) revealed Resident #44 received Risperdal 1 mg on 02/07/24, 02/09/24, 02/11/24, 02/13/24, 02/15/24, 02/17/24, 02/19/24, 02/21/24, 02/23/24, 02/25/24, and 02/27/24. Resident #44 was administered seven additional dosages of Risperdal 1 mg beyond what was ordered. Interview on 03/05/24 at 1:54 P.M. with the Registered Nurse (RN) [NAME] President (VP) of Clinical #406 verified Resident #44 was administered Risperdal 1 mg for about two weeks beyond the ordered one week discontinuation date. Review of the facility policy titled,Administration and Documentation of Medications, revised May (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366039 If continuation sheet Page 4 of 6 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 366039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Point Place 6101 N Summit St Toledo, OH 43611 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 0758 Level of Harm - Minimal harm or potential for actual harm 2021, revealed medications ordered for a specific number of days or for specific days were to be indicated on the medication administration record. Nurses were responsible for the proper administration of all medications scheduled during their shifts. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366039 If continuation sheet Page 5 of 6 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 366039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Point Place 6101 N Summit St Toledo, OH 43611 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **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 maintain a complete and accurate medical record. This affected one (#51) of 16 resident medical records reviewed. The facility census was 65. Findings include: Review of the medical record for Resident #51 revealed the resident was admitted on [DATE] and had diagnoses that included chronic kidney disease and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #51, dated 12/14/23, revealed the resident was assessed with moderately impaired cognition and renal disease. Review of a nursing progress note for Resident #51, dated 02/23/24, revealed the nurse practitioner ordered a transfer to the hospital for evaluation and treatment. Further review of the progress note revealed it did not include a reason for Resident #51's transfer, such as the signs or symptoms exhibited by Resident #51 to necessitate a hospital transfer, nor any indication of the events leading up to the notification made to the nurse practitioner. Review of a nursing progress note for Resident #51, dated 02/24/24, revealed the resident returned from the hospital (just after midnight), with a diagnosis of acute cystitis (inflammation of the bladder typically caused by infection) with hematuria (blood in the urine). The record indicated Resident #51 was treated with a five-day course of antibiotics. Interview on 03/06/24 at 4:20 P.M. with Assistant Director of Nursing (ADON) #359 revealed Resident #51 complained of pain and urinary frequency on 02/23/24 which prompted the nurse on duty to notify the nurse practitioner who then ordered the hospital transfer. ADON #359 confirmed the medical record documentation for Resident #51 did not include a reason for, nor the signs and/or symptoms exhibited by the resident, leading up to this hospital transfer. Review of a policy titled, Documentation Guidelines: All Departments, last revised December 2021, confirmed the medical record shall include all relevant information, including assessment data, pertaining to a resident interaction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366039 If continuation sheet Page 6 of 6