Inspection·September 9, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few Resident #47 had a Secure Care Bracelet (an alarming device when exiting the facility) in place prior to the elopement, and its functionality was tested, and it was determined to be functional. X-rays were obtained and it was discovered Resident #47 had a mildly displaced fracture of the distal fibula of her right leg. At this time, Resident #47 was transported to the hospital emergency room (ER) for evaluation. Review of the SRI revealed Resident #47 was last seen in her room by staff on 07/29/25 at approximately 2:00 A.M. by Certified Nursing Assistant (CNA) #175. It was determined Resident #47 exited the facility through a door that was not locked due to no power supply. An investigation conducted by Maintenance Director #137 on 07/29/25 determined that the main power supply to the door had failed. Maintenance Director #137 was able to replace the rechargeable battery in the door and return it to functionality until it was able to be repaired by the vendor. Review of the SRI revealed the door vendor was at the facility on 07/30/25 and determined the cause of the power failure to this door was due to the power supply to the door, located in the facility attic, was beginning to be dislodged. During an interview on 09/04/25 at 10:43 A.M., Maintenance Director #143 revealed all exit doors are locked with electronic locks, and each has a backup battery. The backup batteries are rechargeable and recharge with there is a power supply to the door. When the batteries are fully charged, they can provide power to the door for up to 24 hours. During the thunderstorm on 07/26/25, the facility lost power from 1:50 P.M. until 9:15 P.M., and when the power returned to the facility, he checked all doors to make sure they were properly functioning and had returned to electrical power from backup battery power. He stated that when doors are on backup battery power, the door will beep approximately every 30 seconds and there were no doors beeping. When Maintenance Director #143 returned to the facility on [DATE] at approximately 7:30 A.M., he noted the panel for the exit door located in the left rear corner of the main dining room was not lit up. At this time, he replaced the backup battery and the panel illuminated properly and he contacted the vendor who services the door and scheduled a service appointment on 07/30/25. He stated that when the vendor who services the door was at the facility on 07/30/25, it was determined the power supply had become interrupted and was supplying intermittent power to this door from the storms earlier in the week and drained the back up battery. Review of the Facility Investigation, dated 07/29/25, revealed Resident #47 exited the facility through the door located in the left rear corner of the facility's main dining room. The door alarm failed due to unknown storm damage. Resident #47 was propelling herself in her manual wheelchair through the grass, when she attempted to walk, her foot became stuck, and she fell to the ground. During an interview on 09/04/25 at 1:20 P.M., the Administrator stated Maintenance Director #143 would continue to check all exit doors weekly to ensure they are locked appropriately. Review of the facility policy titled, Wandering and Elopement, dated 01/02/24, revealed the facility ensures residents who exhibit wander behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care. Under the category of procedure for locating a missing resident, the policy indicated: any staff member becoming aware of a missing resident will alert personnel using approved protocol. The designated facility staff will look for the resident. Appropriate reporting requirements for the state survey agency should be conducted. As a result of the incident, the facility implemented the following corrective actions to correct the deficient practice by 07/30/25: On 07/29/25 at 3:00 A.M., Resident #47 was observed missing, and the facility missing resident protocol was implemented. Upon observation that Resident #47 was not in her room, CNA #175 notified LPN #208 that Resident #47 was not in her room and staff began searching for Resident #47. On 07/29/25 at 3:15 A.M., Resident #47 was found, by Licensed Practical Nurse (LPN) #208 and returned to the inside of the facility. On 07/29/25 at 3:20 A.M., (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366039 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 366039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete a head-to-toe assessment was performed by LPN #208 and which revealed Resident #47's right ankle and right knee were swollen and painful and she had a bruise on her right palm. On 07/29/25 at 3:25 A.M., a headcount was performed, and all residents were accounted for. On 07/29/25 at 3:30 A.M., Resident #47's physician was notified, and an x-ray was ordered. On 07/29/25 at 3:30 A.M., Resident #47 was placed on every 15-minute checks. On 07/29/25 at 3:33 A.M., the on-call nurse manager, LPN #138, was notified. On 07/29/25 at 3:35 A.M., Resident #47's emergency contact was notified. On 07/29/25 at approximately 7:30 A.M., Maintenance Director #143 replaced the battery in the door Resident #47 exited through, returning it to full functionality. On 07/29/25, the inter-disciplinary team members met to review residents' current care plan and update as needed, interventions, and elopement assessment also completed. On 07/29/25, x-ray was completed, and results were received revealing a mildly displaced fracture of the distal fibula on Resident #47's right leg. Resident #47's emergency contact and Nurse Practitioner (NP) #301 were notified and Resident #47 was taken to the emergency room for treatment. On 07/29/25 at 5:15 P.M., Resident #47 was transported to the ER. Resident #47 revealed she returned to the facility with a soft cast and orders to follow up with an orthopedic surgeon. On 07/29/25, Director of Nursing Services (DNS) completed new Elopement Evaluations for all current residents and elopement evaluation scores have been reviewed to identify any residents at risk for elopement. On 07/29/25, all at risk for elopement residents care plans were reviewed and interventions reviewed for accuracy. All resident elopement binders, located at the front desk and nursing stations, were reviewed to ensure accuracy. All residents with Secure Care bands in place had placement and expiration date verified. On 07/29/25, all doors with Secure Care system tested by Maintenance Director #143, to ensure all exit doors were locked appropriately. On 07/29/25, Director of Nursing Services (DNS) or designee educated all staff on the elopement policy, and any employees unable to be educated on this date will receive education prior to their next worked shift. On 07/30/25, ICU Security Solutions was at facility and checked all security doors and alarms and made repairs from storm earlier in the week. On 07/30/25, an elopement drill was conducted on all three shifts. On 07/29/25, Director of Nursing Services (DNS) or designee educated all staff on the elopement policy, and any employees unable to be educated on this date will receive education prior to their next worked shift. Review of the staff in-service dated 07/29/25 revealed staff members were educated on exit-seeking behaviors, staff responsibilities, and what to do if an elopement occurs while you're working, review of staff sign-in sheets revealed all staff were provided education on elopements on 07/29/25 or prior to their next worked shift. Interviews on 09/04/25 and 09/08/25 with CNA #141, CNA #143, CNA #155, Director of Housekeeping #188, LPN #132, LPN #300, Registered Nurse (RN) #103, RN #113, RN #124, and RN #195 revealed they were educated on the facilities elopement policies and procedures and possessed appropriate knowledge in what do to in the event of an elopement. Review of two additional residents (#12 and #33) revealed no concerns with supervision and elopements. This deficiency represents non-compliance investigated under Complaint Number 2601843. Event ID: Facility ID: 366039 If continuation sheet Page 3 of 3