Inspection·May 27, 2021

F 0561 Level of Harm - Minimal harm or potential for actual harm Interview on 05/25/21 at 11:02 A.M. with Stated Tested Nurse Aide (STNA) #160 revealed the facility did not have designated smoking times and Resident #46 was assisted whenever someone could take her out. STNA #160 stated staff were not designated to assist residents with smoking and staff would sometimes refuse to take residents to the smoking area just because they did not want to take them or think it was not their responsibility. Residents Affected - Few Observation on 05/25/21 at 1:04 P.M. revealed Resident #46 requesting to go outside to smoke. STNA #200 was sitting at the nurse's station and stated to the resident that it was not time to smoke yet. Interview on 05/25/21 at 1:05 P.M. with STNA #200 revealed the activities department was responsible for providing assistance to residents with smoking. STNA #200 stated there were no designated smoking times and residents were able to smoke whenever activities could take them. While there was no designated time to smoke, STNA #200 stated residents were usually assisted outside after lunch at around 1:30 P.M. Interview on 05/25/21 at 1:55 P.M. with Resident #46 revealed she still had not been assisted to the smoking area to smoke. Resident #46 stated the only time she had been able to smoke today was around 10:00 A.M., even though she had requested to several times. Observation on 05/25/21 at 1:59 P.M. revealed Resident #46 asked STNA #200 if it was time to smoke yet. STNA #200 told Resident #46 someone would get her when it was time. Observations on 05/25/21 from 2:04 P.M. to 2:42 P.M. of the courtyard, identified as the designated smoking area, revealed no residents, including Resident #46, had been taken to smoke. Observation on 05/25/21 at 2:43 P.M. revealed Resident #46 was assisted to the courtyard to smoke by nursing staff. Interview on 05/25/21 at 4:45 P.M. with Activities Director (AD) #215 revealed all staff were responsible for assisting residents to smoke when they wanted to. AD #215 stated the facility did not have designated smoking times to allow residents to smoke based on their preferences. AD #215 stated not all residents wanted to smoke at the same time and any staff who was available were to assist residents when they requested to smoke. AD #215 stated if staff on the floor were not available to assist a resident to the smoking area when they requested, the staff were to call activities for assistance. Review of the facility's policy titled Resident Rights, revised 10/2019, revealed all facilities are to respect the rights of their residents and provide them reasonable and practicable services/accommodations that provide residents dignity without exploitation. Additionally, residents are entitled to exercise their rights and privileges to the fullest extent possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 2 of 19 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 366188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Toledo Snf 131 North Wheeling Street Toledo, OH 43605 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on medical record review, staff interview and facility policy review, the facility failed to develop a comprehensive care plan for residents to identify individual service needs. This affected two residents (#42 and #46) of three residents reviewed for care plans. The facility census was 72. Findings include: 1. Review of the medical record for Resident #42 revealed an admission date of 03/30/21. Diagnoses included emphysema, stage three chronic kidney disease, myasthenia gravis with (acute) exacerbation, difficulty walking, spondylosis, and other idiopathic peripheral autonomic neuropathy. Review of the Minimum Data Set (MDS) assessment, dated 04/30/21, revealed Resident #42 was cognitively intact; required extensive two-person assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of the care plan for Resident #42 revealed a baseline, admission care plan had been completed on 03/30/21. The medical record was absent of a comprehensive care plan. Interview on 05/27/21 at 8:24 A.M. with Minimum Data Set (MDS) Nurse #195 verified a comprehensive care plan had not been completed for Resident #42, stating they had missed it. 2. Review of the medical record for Resident #46 revealed and admission date of 11/12/20. Diagnoses included chronic obstructive pulmonary disease (COPD), injury of head, nicotine dependence, cigarettes, dysphasia, shortness of breath, and localized swelling, mass and lump, lower limb, bilateral. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/08/21, revealed Resident #46 was moderately cognitively impaired, required extensive one-person assistance with Activities of Daily Living (ADLs), and received scheduled pain medication. Review of the Resident Smoking Assessment, dated 05/25/21, revealed Resident #46 was not able to handle a lighter and Resident #46 exhibited physical ability to smoke with minimal assistance as evidenced by the evaluation of motor skills. Review of the care plan revealed interventions for Resident #46 related to pain were included on the admission care plan on 11/12/20 and marked as resolved on 02/04/21. There were no identified pain management interventions for Resident #46 after 02/04/21. The care plan was silent for any smoking related interventions. Interview on 05/25/21 at 3:32 P.M. with the Director of Nursing (DON) verified there were no smoking related interventions identified in Resident #46's care plan. Interview on 05/27/21 at 8:27 A.M. with Minimum Data Set (MDS) Nurse #195 verified pain management interventions were not addressed in Resident #46's care plan. Review of the facility's policy titled Smoking-Residents, revised 11/22/17, revealed any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be altered to these issues. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 3 of 19 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 366188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Toledo Snf 131 North Wheeling Street Toledo, OH 43605 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 0656 Level of Harm - Minimal harm or potential for actual harm Review of the facility's polity titled Care Plans, revised 09/2019, revealed the facility must develop a comprehensive, person-centered care plan, consistent with resident rights, that shall incorporate goals, objectives, and preferences that lead to the resident's highest obtainable level of independence. Additionally, care plans will be modified accordingly, and efforts will be made to inform the resident in advance of any modifications. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 4 of 19 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 366188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Toledo Snf 131 North Wheeling Street Toledo, OH 43605 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #8's closed medical record revealed an admission date of 01/26/21. Diagnoses included hypertension, cellulitis, sciatica, cervical cancer, alcohol abuse, and chronic obstructive pulmonary disease. Resident #8 was discharged from the facility on 05/17/21. Residents Affected - Some Review of an admission nursing assessment, dated 01/26/21, revealed Resident #8 was alert and oriented to person, place, and time and assessed with a deep tissue injury (DTI) (a persistent non-blanchable deep red, maroon or purple discoloration) to the left heel. There were no measurements of the DTI on the admission nursing assessment and no documentation of Resident #8 with any other pressure ulcers on admission. Review of an admission baseline care plan, dated 01/26/21, revealed Resident #8 had a care plan in place for pressure ulcers with interventions to follow wound care protocol, report skin breakdown and redness, measure open wounds at least weekly, and administer treatment as ordered. Review of Resident #8's comprehensive care plan, dated 02/09/21, revealed pressure ulcer interventions including wound care and dressing changes as ordered. Review of an admission Minimum Data Set (MDS) assessment, dated 02/05/21, revealed Resident #8 was cognitively intact, required extensive two-plus persons physical assistance with bed mobility, had no days in the look back period with care rejected, and was assessed with two unstageable pressure ulcers (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar). Review of the MDS assessment, dated 05/07/21, revealed Resident #8 was assessed as rejecting care on a daily basis and remained with two unstageable pressure ulcers. Review of the physician orders, dated between 01/26/21 and 01/28/21, revealed no wound dressing were ordered for Resident #8's bilateral leg wounds. The physician order, dated 01/29/21, revealed Resident #8 was ordered to have wraps applied to bilateral lower extremities during daytime and off at night daily. This order was discontinued on 02/08/21. Review of facility and wound care clinic wound assessments revealed Resident #8's wounds were not assessed again until 02/05/21. At this time Resident #8 was assessed with a DTI cluster to the right heel and posterior leg measuring 21.5 centimeters (cm.) long by 13.5 cm. wide by 0.1 cm. deep, a DTI to the left heel measuring 10.0 cm. long by 3.4 cm. wide by 0.1 cm. deep, a DTI to the left anterior ankle measuring 1.0 cm. long by 5.3 cm. wide by 0.1 cm. deep, a DTI cluster to the right anterior ankle measuring 4.2 cm. long by 6.2 cm. wide by 0.1 cm. deep, a DTI to the right medial foot measuring 5.3 cm. long by 1.4 cm. wide by 0.1 cm. deep, and a right lateral foot DTI measuring 8.0 cm. long by 2.5 cm. wide by 0.1 cm. deep. Further review of weekly wound assessments revealed Resident #8's wounds were not assessed weekly between 02/12/21 and 02/26/21 or between 02/26/21 and 03/12/21. Review of a physician order, dated 02/05/21, revealed Resident #8 was ordered to have her left posterior ankle covered with a gauze pad and wrapped with a bandage daily and have the right calf cleaned with normal saline, apply a medication ointment, cover with gauze, and wrap with a bandage daily. These orders were discontinued on 02/19/21. The physician order, dated 02/19/21, revealed Resident #8 was ordered to have the right and left lower extremity wounds cleaned with betadine soaked gauze, apply an absorbent pad to the wounds, and wrapped with a bandage daily. This order was continued (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 5 of 19 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 366188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Toledo Snf 131 North Wheeling Street Toledo, OH 43605 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some until 03/29/21. On 03/26/21, a physician order was written for Resident #8 to have her bilateral legs cleaned with antibacterial soap and water, rinsed well, apply betadine to all wound areas, cover with an absorbent pad, and wrap with a cast pad and gauze wraps daily at bedtime. Review of the February, March, April, and [NAME] 2021 TARs revealed no documentation of Resident #8's wound being treated on 02/07/21, between 02/12/21 and 02/17/21, 02/28/21, 03/03/21, between 03/10/21 and 03/15/21, 03/17/21, 03/20/21, 03/25/21, 03/28/21, 03/30/21, 04/01/21, 04/08/21, 04/10/21, 04/12/21, 04/26/21, between 04/28/21 and 04/30/21, between 05/02/21 and 05/05/21, and 05/13/21. Review of the nursing progress notes and skilled nursing notes dated between 01/26/21 and 05/17/21 revealed no documentation of wound care provided for Resident #8 for the missing dates on the TARs. Review of a vascular surgeon assessment, dated 04/26/21, revealed Resident #8 stated the nursing home she was in did not change her dressings routinely. A telephone interview was completed on 05/26/21 at 12:58 P.M. with Assistant Director of Nursing (ADON) #1 verified Resident #8 was admitted to the facility with wounds to both her right and left legs. ADON #1 stated she assisted with making appointments for Resident #8's wound care clinic, and stated all of the documentation of Resident #8's wound care should be in the electronic health record. ADON #1 stated the documentation of Resident #8's wound care treatments should be in the TARs but may also be in the nursing progress notes. Interview on 05/27/21 at 12:48 P.M. with Director of Nursing (DON) #1 verified Resident #8's missing weekly wound assessments in February and March 2021 as well as the missing documentation of Resident #8's wound care being provided in February, March, April, and May 2021. Review of a facility policy titled, Skin Care and Wound Treatment Protocol, revised August 2019, revealed the facility will ensure the resident's skin and/or wound area(s) are treated and cared for in an attempt to keep area(s) from becoming open or worsening in the facility's care, and will monitor and document interventions and outcomes. Review of a facility policy titled, Dressing Change, revised October 2020, revealed dressing changes will occur according to physician or nurse practitioner order and as needed including documentation of wound measurements, discomfort with dressing change, and drainage. This deficiency substantiates Complaint Number OH00122585. Based on observation, staff interview, resident record review, and review of the facility's policies, the facility failed to complete weekly wound assessments and failed to complete wound treatments as physician ordered. This affected four (#8, #53, #57, and #69) of six residents reviewed for pressure ulcers. The facility identified eight residents with pressure ulcers. The facility census was 72. Findings include: 1. Review of medical record for Resident #69 revealed an admission date of 04/25/20. Diagnosis included acute respiratory failure with hypoxia, decreased white blood cell count, essential (primary) hypertension, moderate protein-calorie malnutrition, type two diabetes mellitus without complications, dementia without behavioral disturbance, muscle weakness, dysphasia, social exclusion and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 6 of 19 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 366188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Toledo Snf 131 North Wheeling Street Toledo, OH 43605 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 0686 rejection, lack of coordination, and difficulty in walking. Level of Harm - Minimal harm or potential for actual harm Review of the Minimum Data Set (MDS) assessment, dated 04/20/21, revealed the resident had significant cognitively impairment. Resident #69 had one Stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed). Residents Affected - Some Review of the physician orders, dated 04/29/21, revealed orders for dressing changes to the resident right and left buttocks. Dressing change orders included, apply calcium alginate to wounds on left and right buttocks and cover with hydrocolloid. The orders were to change the dressing every other day and as needed if soiled. Review of the wound evaluation, dated 05/05/21, revealed Resident #69 had a full thickness pressure wound assessed as a Stage III. The wound measured 1.0 centimeters (cm.) long by 0.9 cm. wide by 0.1 cm. deep. The assessment indicated the wound was draining a moderate amount serosanguinous exudate. Review of the Treatment Administration Record (TAR) revealed Resident #69 received a dressing change on 05/23/21. Review of Resident #69's wound assessments revealed there were no wound assessments completed between the dates of 02/19/21 to 03/16/21 and 05/06/21 to 05/24/21. Observation and interview on 05/25/21 at 2:02 P.M. revealed Licensed Practical Nurse (LPN) #140 administering a wound treatment to Resident #69. The resident was undressed and turned to his left side. There was no dressing observed to be in place on the resident's buttocks/coccyx region. The resident's wounds were not visible at the time of observation due to the amount of dried cream in the area. LPN #140 attempted to cleanse the area but stopped due to the resident's discomfort. LPN #140 proceeded to complete the dressing change using hydrocolloid was applied to two small areas near the coccyx which LPN #140 described as the open areas. A foam dressing was placed over the area. LPN #140 verified a dressing should have been in place and was not. LPN #140 stated she had not been informed by any of the aide staff that Resident #69's dressing was no longer applied or needed changed. Interview on 05/25/21 at 2:16 P.M. with State Tested Nursing Assistant (STNA) #150 revealed she had been caring for Resident #69 on day shift. STNA #150 stated she changed Resident #69's brief when she first arrived around 7:00 A.M., around 12:00 P.M., and around 1:45 P.M. STNA #150 stated there were not any dressings in place on the resident's buttock area at the time she changed his brief. STNA #150 stated she cared for Resident #69 in the past and that he had dressings in place during her previous encounters. STNA #150 further explained that upon her first care with the resident at 7:00 A.M., she noted there was not a dressing in place, had assumed he was no longer requiring dressing changes, and completed incontinence care by applying barrier cream to the area. STNA #150 confirmed she did not report to the nurse that there was not a dressing in place because she thought the treatment had been discontinued. Interview on 05/26/21 at 9:03 A.M. with Director of Nursing (DON) verified there were no weekly wound assessments completed between the dates of 02/19/21 to 03/16/21 and 05/06/21 to 05/24/21. 2. Review of the medical record for Resident #53 revealed an admission date of 01/08/21. Diagnoses included acute kidney failure, heart failure, anemia, hypo-osmolality and hyponatremia and pulmonary hypertension due to lung diseases and hypoxia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 7 of 19 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 366188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Toledo Snf 131 North Wheeling Street Toledo, OH 43605 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the care plan revealed Resident #53 was at risk for skin breakdown due to incontinence and needed help for bed mobility. Interventions included reposition frequently during the day when in bed or chair. Reposition as tolerated during the night. Monitor skin during baths and weekly and treatments as ordered. Review of the significant change Minimum Data Set (MDS) assessment, dated 04/26/21, revealed Resident #53 was severely cognitively impaired, required extensive two person assist with bed mobility, total dependence of two persons for transfers, personal hygiene, and toilet use. Resident #53 did not have a pressure ulcer and was under hospice care. Review of the skin assessment, dated 04/29/21, revealed Resident #53 had a stage three coccyx pressure ulcer. Review of the physician orders revealed Resident #53 had the following treatment orders: weekly skin assessment on day shift; observe wounds daily for signs and symptoms of infection, increased redness, swelling, pain, drainage or warm to touch or increased temperature, every shift; wash sacral/coccyx with soap and water, dry completely, and cover with foam dressing every three days and as needed until healed; and house barrier cream every shift and as needed for incontinence care, every shift for protection. Review of the Treatment Administration Record (TAR), dated April 2021, revealed Resident #53 did not receive the following treatments as ordered: observe wounds daily for signs and symptoms of infection, increased redness, swelling, pain, drainage or warm to touch or increased temperature on 04/15/21 and 04/25/21 on the day shift and 04/06/21, 04/13/21, and 04/23/21 on the evening shift. Resident #53 also did not receive house barrier cream on 04/15/21 and 04/25/21 on the day shift and 04/06/21, 04/13/21 and 04/23/21 on the evening shift. Review of the TAR, dated May 2021, revealed the following ordered treatments were not administered: weekly skin assessment on 05/03/21, 05/17/21 and 05/24/21; observe wound(s) daily for signs/symptoms of infection on 05/01/21, 05/02/21, 05/03/21, 05/05/21 and 05/21/21 on the day shift and on 05/01/21 on the evening shift; wash sacral/coccyx with soap and water, dry completely, and cover with foam dressing every three days on 05/06/21 and 05/12/21; and house barrier cream on 05/01/21, 05/02/21, 05/21/21 on the day shift and 05/01/21 on the evening shift. Interview on 05/27/21 at 8:04 A.M. with the Director of Nursing (DON) verified the TARs did not reflect treatments were provided as ordered. 3. Review of the medical record for Resident #57 revealed an admission date of 04/12/21. Diagnoses included acute kidney failure, hyperkalemia, hepatic failure, essential (primary) hypertension, nonrheumatic aortic (valve) insufficiency, and type II diabetes mellitus without complications. Review of the Minimum Data Set (MDS) assessment, dated 04/19/21, revealed Resident #57 was severely cognitively impaired, required two-person extensive assistance with transfers, dressing, toilet use, personal hygiene and had a stage three pressure ulcer upon admission. Review of the care plan revealed Resident #57 had a stage three pressure ulcer due to poor bed mobility. Interventions included treatments as ordered, follow with wound care, and monitor skin during care, baths, weekly skin, and treatments. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 8 of 19 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 366188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Toledo Snf 131 North Wheeling Street Toledo, OH 43605 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 0686 Level of Harm - Minimal harm or potential for actual harm Review of the physician orders, dated 05/12/21, revealed Resident #57 had a treatment order to apply Triad paste (used to promote wound healing) to cover wound twice daily. Review of the TAR, dated May 2021, revealed Resident #57 did not receive Triad paste to cover wound at breakfast on 05/13/21 and 05/19/21. Residents Affected - Some Interview on 05/27/21 at 7:54 A.M. with the Director of Nursing (DON) verified the TAR did not reflect Resident #57 received Triad paste to cover wound at breakfast on 05/13/21 and 05/19/21 as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 9 of 19 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 366188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Toledo Snf 131 North Wheeling Street Toledo, OH 43605 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on medical record review, staff interview, and review of the facility's policy, the facility failed to perform routine care for indwelling urinary catheters including cleaning the catheter insertion site. This affected one (#232) of one resident reviewed for catheter care. The facility identified two residents with indwelling urinary catheters. The facility census was 72. Findings include: Review of the medical record for Resident #232 revealed an admission date of 05/20/21. Diagnoses included Alzheimer's Disease, anxiety disorder, and urinary retention. Review of the physician orders, dated 05/20/21, revealed an order to insert and maintain a indwelling catheter for urinary retention. There were no physician orders for performing routine catheter care. Review of the baseline care plan, dated 05/20/21, revealed there was no evidence for performing routine catheter care. Review of the Treatment Administration Records (TAR) and Medication Administration Records (MAR) from 05/20/21 through 05/25/21 revealed there was no evidence routine catheter care had been performed. Review of the State Tested Nursing Assistant (STNA) documentation from 05/20/21 through 05/25/21 revealed no evidence that routine catheter care had been performed. Interview on 05/25/21 at 11:41 A.M. with Hospice Registered Nurse (HRN) #110 revealed she had been seeing Resident #232 almost everyday since her admission. HRN #110 stated Resident #232 was admitted to the facility with an indwelling urinary catheter in place for a diagnosis of urinary retention. HRN #110 stated the hospice services team was not performing any routine care related to the catheter unless there was an issue and the facility staff requested them to. Interview on 05/26/21 at 10:12 A.M. with STNA #120 revealed she was caring for Resident #232 that day. STNA #120 stated she performs catheter care on Resident #232 once a shift by cleansing the tube and the perineal area with soap and water once a shift. STNA #120 stated there was not a place to document the care she performs with the catheter in the medical record. STNA #120 was unsure when catheter care had last been performed on the resident. Interview on 05/26/21 at 10:17 A.M. with Unit Manager (UM) #130 revealed any residents in the facility who have an indwelling urinary catheter should receive routine catheter care at least once per shift from the aide staff. UM #130 stated the routine catheter care should be documented when completed. UM #130 stated the routine catheter care included cleansing the catheter tube and the area around the insertion point. UM #130 could not verify if Resident #232 received any catheter care from 05/20/21 through 05/25/21. UM #130 verified there was no evidence the task was completed in the resident's medical record. UM #130 further revealed there should be a specific physician order for performing routine catheter care for residents with indwelling catheters. UM #130 further stated catheter care would also be a care plan intervention for residents who have indwelling catheters. UM #130 verified an order was never put in and the baseline care plan did not include any interventions for this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 10 of 19 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 366188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Toledo Snf 131 North Wheeling Street Toledo, OH 43605 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 0690 task. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled Standards for Catheters, dated 02/2000, revealed the urinary tract is a common site for infection. The policy stated that staff will manage indwelling catheters and provide appropriate care to help prevent urinary tract infections. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 11 of 19 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 366188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Toledo Snf 131 North Wheeling Street Toledo, OH 43605 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #19 medical record revealed an admission date of 05/11/21. Diagnoses included fibromyalgia, disorder of the kidney and ureter, dysphagia, acidosis, diabetes mellitus type II, major depression, and unspecified dementia without behavioral disturbances. Observation on 05/26/21 at 8:00 A.M., revealed Resident #19 sleeping in bed with her eyes closed and a plastic medication cup with medications inside sitting on her bedside table to the left of the resident. Observation inside the medication cup revealed a small white round tablet and a half orange and half white capsule. Interview with on 05/26/21 at 8:13 A.M., Licensed Practical Nurse (LPN) #650 stated she had not administered any medications to Resident #19 on 05/26/21 and verified the medication cup with medications inside sitting on Resident #19's bedside table. Review of Resident #19's May 2021 medication administration record (MAR) with LPN #650 revealed the blood pressure medication amlodipine and and the acid reflux medication Prilosec were documented as administered to Resident #19 on 05/26/21 at 5:51 A.M. Review of Resident #19's medication cards in the medication cart at this time confirmed the medications in the medication cup left at Resident #19's bedside was an amlodipine 2.5 milligram (mg) tablet and a Prilosec 20 mg capsule. Review of the facility policy titled Medication Administration-Preparation and General Guidelines revised 08/2014, revealed medications are administered only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications, in accordance with written orders of the prescriber. Additionally, the policy stated the resident is always observed after administration to ensure that the dose was completely ingested. Review of the policy titled Pharmacy Services Overview, revised 10/26/17, revealed the facility shall develop, implement, evaluate, and revise (as necessary) the procedures for the provision of all aspects of pharmacy services, including ordering, delivery and acceptance, storage, distribution, preparation, dispensing, administration, disposal, document, and reconciliation of all medications and biologicals in the facility. 2. Review of the medical record for Resident #9 revealed an admission date of 02/20/21. Diagnoses included malignant neoplasm of colon, systemic lupus erythematosus, severe protein calorie malnutrition, asthma, depression, dysphagia, anemia, and muscle weakness. Review of the comprehensive Minimum Data Set (MDS) assessment for Resident #9, dated 02/20/21, revealed the resident had intact cognition, scoring a 15 out of 15 on the Brief Interview for Mental Status (BIMS). Review of the care plan for Resident #9 dated 02/20/21, revealed the resident had basic care needs. Interventions included administering medication per physician order. Review of the Medication Administration Record (MAR) for Resident #9 for 05/24/21 revealed medications that were tablets or capsules administered at the 8:00 A.M. hour included: Meclizine (antihistamine) 25 milligrams (mg) half tablet, Midodrine (blood pressure) 10 mg, zinc sulfate 220 mg, vitamin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 12 of 19 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 366188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Toledo Snf 131 North Wheeling Street Toledo, OH 43605 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few C 500 mg, Potassium Chloride 20 milliequivalents (mEq), ferrous sulfate (iron) 325 mg, folic acid 1 mg, magnesium 400 mg, Capecitabine (chemotherapy) 500 mg, Sertaline (antidepressant) 100 mg, Memantine (dementia) 10 mg, Senna 8.6 mg with Docusate Sodium 50 mg (constipation), and Omeprazole 20 mg (reflux). Interview and observation on 05/24/21 at 10:23 A.M., revealed Resident #9 resting in bed in his room. A medicine cup containing several pills was observed on Resident #9's bedside table. Resident #9 stated in an interview that the nurse brought them in earlier that morning, but he fell asleep before taking the pills. There were not any staff in the area of the resident's room at the time of the observation. Interview and observation on 05/24/21 at 10:30 A.M., with Licensed Practical Nurse (LPN) #100 revealed she had administered Resident #9's medication earlier that morning. LPN #100 stated that she administered all of Resident #9's morning medication around 7:45 A.M. LPN #100 stated she watched the resident for a moment and thought he was getting ready to take the medication and left the room. She could not verify if the resident took any of his medication at the time of administration. Observation with LPN #100 confirmed Resident #9's medication remained on his bedside table. LPN # 100 asked Resident #9 why he had not taken the medication yet and the resident stated he fell asleep. Based on observation, staff interviews, medical record reviews, and review of facility policies, the facility failed to ensure medications were administered in accordance with physician orders. This affected three (#9, #19, and #57) residents reviewed for pharmacy services. The census was 72. Findings include: 1. Review of Resident #57's medical record revealed and admission date of 04/12/21. Diagnoses included acute kidney failure; hyperkalemia; hepatic failure, unspecified without coma; essential (primary) hypertension; nonrheumatic aortic (valve) insufficiency; and type II diabetes mellitus without complications. Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #57 was severely cognitively impaired; required two person extensive assistance with transfers, dressing, toilet use, and personal hygiene and had a stage three pressure ulcer upon admission. Review of current physician orders for Resident #57 revealed the following order, with a start date of 05/14/21: Clotrimazole 1% cream (medication used to treat skin infections caused by fungus, such as yeast) every shift to groin area twice daily for 14 days if open skin area present for antifungal. Review of the care plan revealed Resident #57 had a stage three pressure ulcer due to poor bed mobility. Interventions included treatments as ordered, follow with wound care, and monitor skin during care, baths, weekly skin, and treatments. Review of the May 2021 Treatment Administration Record (TAR) for Resident #57 revealed Clotrimazole 1% cream was not administered as ordered on 05/15/21, 05/16/21, and 05/19/21 on the day shift and 05/16/21 and 05/17/21 on the evening shift. Interview on 05/27/21 at 7:54 A.M., with the Director of Nursing (DON) verified Clotrimazole 1% cream was not administered as ordered on 05/15/21, 05/16/21, and 05/19/21 on the day shift and 05/16/21 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 13 of 19 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 366188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Toledo Snf 131 North Wheeling Street Toledo, OH 43605 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 0755 and 05/17/21 on the evening shift. Level of Harm - Minimal harm or potential for actual harm Interview on 05/27/21 at 12:23 P.M., of Licensed Practical Nurse (LPN) #140 verified Resident #57 was being treated for a fungal infection in the groin area. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 14 of 19 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 366188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Toledo Snf 131 North Wheeling Street Toledo, OH 43605 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, medical record review, and review of a drug manufacturer's administration instructions, the facility failed to prime an insulin pen prior to administration. This affected one (#72) of three residents observed during medication administration. The facility identified 17 residents with orders for insulin. The census was 72. Residents Affected - Few Findings include: Review of Resident #72's medical record revealed an admission date of 02/16/21. Diagnoses included morbid obesity, diabetes mellitus type II, major depression, and essential hypertension. Review of a physician order dated 03/04/21 revealed Resident #72 was ordered Lantus insulin 20 units subcutaneously (SQ) daily. Observation on 05/26/21 at 8:42 A.M., revealed LPN #650 remove Resident #72's Lantus insulin pen from the medication cart and dialed 20 units of insulin on the dosage indicator and showed it to the Surveyor to verify the dosage. LPN #650 then entered Resident #72's bedroom with the rest of her morning medications and administered the insulin into the back of Resident #72's left upper arm without first priming the insulin pen. Interview on 05/26/21 at 8:50 A.M., with LPN #650 verified she did not prime the insulin pen prior to dialing up the correct 20 units dosage for Resident #72. LPN #650 verified she was not aware the insulin pen required to be primed before dialing the require units on the insulin pen to ensure the correct dosage was given. Observation on 05/26/21 at 1:12 P.M. and on 05/27/21 at 11:42 A.M., revealed Resident #72 was calm with no acute changes in condition. Review of a Lantus insulin pen manufacturer's instructions, dated 2020, revealed after attaching the needle to the insulin pen, the user should perform a safety test where the user dials a test dose of two units and press the button all the way to check and see if insulin comes out of the needle. If no insulin comes out, repeat the test two more times. After the insulin was verified to come out of the needle the user can then dial the required dose. A safety test should always be performed before each injection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 15 of 19 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 366188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Toledo Snf 131 North Wheeling Street Toledo, OH 43605 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interviews, and review of facility policies, the facility failed to ensure the walk-in refrigerator was clean; food items in the upright kitchen refrigerator were properly covered, labeled, and dated; and failed to cover food during transportation and distribution to residents. This had the potential to affect 71 of 72 residents who receive food from the kitchen. The facility identified one resident (#19) who did not receive food from the kitchen and directly affected six residents (#6, #21, #42, #45, #53, and #69) who received a lunch meal tray in their resident room. The facility census was 72. Findings include: 1. Observation on 05/24/21 at 9:23 A.M., revealed the upright kitchen refrigerator in the Labuhn Rehabilitation Center with seven grilled cheese sandwiches not labeled or dated, seventeen berry fruit cups with whipped topping not covered, labeled or dated, and egg salad like food not labeled or dated. Interview on 05/24/21 at 9:25 A.M., with Dietary Manager #175 verified the grilled cheese sandwiches were not labeled or dated, the fruit with whipped topping was not covered, labeled, or dated, and the egg salad was not labeled or dated. 2. Observation on 05/25/21 at 11:15 A.M., revealed the walk-in kitchen refrigerator had two storage shelves with thick dark green and black mold like substances on the shelves ranging in size from approximately half an inch to three inches. Interview on 05/25/21 at 11:35 A.M., with Dietary Manager #175 verified the substance on the kitchen shelving unit appeared to be mold. Dietary Manager #175 revealed she had cleaned one of the other shelves the previous week and reported there is a kitchen cleaning schedule but does not have information of the last time the walk-in refrigerator was cleaned. 3. Observation on 05/24/21 at 12:13 P.M., revealed an open meal cart with lunch meal trays which included uncovered berries with whipped cream topping served to six (#6, #21, #42, #45, #53, and #69) residents in their resident rooms. Interview on 05/24/21 at 12:17 P.M., with State Tested Nursing Assistant (STNA) #150 verified the berry fruit cup with whipped cream was uncovered during transportation and distribution to residents receiving meal trays. Review of the policy titled, Food Storage, revised 11/01/20, revealed food is stored, prepared, and transported by methods designed to prevent contamination or cross contamination. The food is stored in an area that is clean, dry, and free from contaminants. All foods should be covered, dated, and labeled. Review of the policy titled, Dietary Cleaning Policy, revised 11/01/20, revealed the food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 16 of 19 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 366188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Toledo Snf 131 North Wheeling Street Toledo, OH 43605 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 observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to accurate document medication administration in the medical record. This affected one (#231) of four residents reviewed for medication administration. The census was 72. Findings include: Review of Resident #231's medical record revealed an admission date of 05/14/21. Diagnoses included acute kidney failure, diabetes mellitus type II, chronic obstructive pulmonary disease, dehydration, ventricular tachycardia, and ischemic cardiomyopathy. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #231 was cognitively intact. Review of a physician order dated 05/15/21 revealed Resident #231 was ordered the antibiotic ceftriaxone two grams intravenously (IV) once daily scheduled for 2:00 P.M. Interview on 05/26/21 at 11:33 A.M., with Licensed Practical Nurse (LPN) #784 stated she would be giving Resident #231 his IV antibiotic around 2:00 P.M., but had other things to do and would not hold the medication if the surveyor was not there to watch when she was ready. The Surveyor informed LPN #784 that he would be there before 2:00 P.M. in order to see the IV medication administered. Interview on 05/26/21 at 1:36 P.M., with LPN #784 stated she was not ready for the IV medication and did not know when she would be giving it. LPN #784 was approached again at 2:01 P.M. and LPN #784 stated she still was not ready, had a new resident admission to complete, and other resident care needs to attend to before she could give Resident #231 his IV medication. Review of the Resident #231's May 2021 medication administration record (MAR) on 05/26/21 at 2:06 P.M. revealed the IV medication was already documented as administered with an administration time of 05/26/21 at 1:08 P.M. Observation on 05/26/21 at 2:11 P.M., revealed Resident #231 laying in his bed with an IV medication connected and administering in his right arm. A closer observation was made of the medication revealed it was his ordered ceftriaxone which was administered. Interview on 05/26/21 at 2:12 P.M., with Resident #231 stated the nurse (LPN #784) had just hooked up his IV medication two minutes before the start of this interview. Interview on 05/26/21 at 2:36 P.M., with LPN #784, and with the Director of Nursing (DON) present, stated she documented in Resident #231's May 2021 MAR that the IV medication was administered on 05/26/21 at 1:08 P.M. but that was not truly when Resident #231 was administered the medication. LPN #784 stated she documented the time in the May 2021 MAR when she removed Resident #231's IV medication from the refrigerator to warm it up before administration. LPN #784 confirmed she administered Resident #231's IV medication on 05/26/21 after 2:01 P.M. when she last told the Surveyor she did not know when the medication was going to be administered. Review of the policy titled, Medication Administration-General Guidelines, revised August 2014, revealed the individual who administers the medication dose records the administration on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 17 of 19 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 366188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Toledo Snf 131 North Wheeling Street Toledo, OH 43605 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 resident's MAR directly after the medication is given. 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: 366188 If continuation sheet Page 18 of 19 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 366188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Toledo Snf 131 North Wheeling Street Toledo, OH 43605 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and staff interview, the facility failed to ensure a resident's personal room and the dining room area (where the resident sat) were cleaned timely, after the resident repeatedly spits on the floor. This directly affected one (#49) and potentially affected fifteen (#7, #11, #16, #20, #24, #25, #27, #29, #32, #33, #40, #44, #62, #65, and #79) additional residents who eat in the 300 hall dining room. The facility census was 72. Findings include: Observation on 05/24/21 at 11:50 A.M., revealed Resident #49 sitting at a table in the 300 hall dining room. Resident #49 was observed to make a sound with his mouth and throat and proceeded to spit on the dining room floor. Interview on 05/24/21 at 11:55 A.M., with Housekeeping #180 revealed Resident #49 spits on his resident room floor and dining room floor often. Housekeeping #180 reported Resident #49 sits by himself in the dining room and staff have to watch where they step. Housekeeping #180 was informed Resident #49 spit on the dining room floor just prior to the conversation. Observation on 05/24/21 at 12:00 P.M., revealed dried phlegm like substance on Resident #49's resident room floor next to the bed closest to the window. The area of dried substance included numerous and undetermined amount of dried fluid substance measuring approximately 8 inches by 4 inches. Observation on 05/25/21 at 11:58 A.M., of Resident #49's resident room floor and the dining room near Resident #49's chair revealed the dried fluid like substance remained on the flooring with no apparent changes. Observation on 05/26/21 at 8:35 A.M., Resident #49's resident room floor and the dining room near Resident #49's chair revealed the dried fluid like substance remained on the flooring with no apparent changes. Interview on 05/26/21 at 8:38 A.M., with State Tested Nursing Assistant (STNA) #185 confirmed the dried fluid like substance on Resident #49's resident room floor and the dining room appeared to be phlegm and could not confirm how long it had been there. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 19 of 19