Inspection·October 19, 2023

F 0584 Coinciding interview with Resident #67 verified it was still too warm in his room. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Safe and Homelike Environment, revised February 2023 revealed the facility would maintain comfortable and safe temperature levels. The facility should strive to keep the temperatures in common areas between 71- and 81-degrees Fahrenheit. If a resident preferred to keep their room below 71 degrees or above 81 degrees, the facility would assess the safety of this practice on the resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 2 of 21 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 10/19/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, staff interview and review of the policy, the facility failed to ensure residents who required staff assistance with activities of daily living, received adequate and timely care to maintain good personal hygiene including nail care and shaving. This affected two residents (#67 and #10) of three residents reviewed for activities of daily living. The facility census was 80: Residents Affected - Few Findings include: 1. Review of the medical record for Resident #67 revealed an admission date of 06/29/23. Diagnoses included protein calorie malnutrition, chronic kidney disease, adjustment disorder, osteoarthritis, and prostate cancer. Review of Resident #67's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #67 was cognitively intact. Resident #67 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #67 was totally dependent on staff for bathing. Resident #67 displayed no behavior during the review period. Review of Resident #67's care plan revised 08/09/23 revealed supports and interventions for the need for assistance with activities of daily living, and chronic pain. Resident #67 was to have nail care provided on his bath days and as necessary. Review of Resident #67's shower sheets revealed Resident #67's received revealed Resident #67 refused all showers. Resident #67 received a bed bath on 09/21/23, 09/23/23, 09/27/23, 09/30/23, 10/11/23, and 10/14/23. Resident #67's nails were not documented as trimmed on any of the days he was bathed. Observation on 10/16/23 at 9:41 A.M., found Resident #67's fingernails to be long and untrimmed. Interview on 10/16/23 at 9:52 A.M., with Resident #67 found him to be alert and aware. Resident #67 reported he had been asking for his fingernails to be clipped and no one had done it. He said he felt like they just ignored him when he asked. He stated they were way too long, and he wanted them trimmed. Interview on 10/17/23 at 9:00 A.M., with State Tested Nursing Assistant (STNA) #388 verified Resident #67's fingernails were to be trimmed on his bathing days. STNA #388 verified Resident #67's fingernails had not been trimmed. Review of the policy titled, Fingernails/Toenails, Care of, revised 02/18 revealed the purpose of the policy was to keep nail beds clean and nails trimmed. Nail care included daily cleaning and regular trimming. 2. Review of Resident #10's medical record revealed an admission date of 02/12/23. Diagnoses included history of COVID-19, type II diabetes, dysphagia, generalized anxiety disorder, major depressive disorder, and spinal stenosis. Review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 3 of 21 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 10/19/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Status (BIMS) score of seven indicating Resident #10 was severely cognitively impaired. Resident #10 required extensive assistance with bed mobility, toilet use and personal hygiene. Resident #10 had delusions and displayed wandering behaviors one to three days during the review period. Review of Resident #10's care plan revised 09/25/23 revealed supports and interventions for the need for assistance with activities of daily living, behavioral symptoms, and risk for falls. Resident #10 required extensive assistance with personal hygiene and was dependent on staff for bathing and or showering. Observation on 10/16/23 at 10:31 A.M., found Resident #10 sitting up in her bed trying to feed herself breakfast. Resident #10 was observed to have a brown substance under the fingernails of both her hands and hair on her upper lip and chin approximately a quarter of an inch long. An interview was attempted with Resident #10, and it was found she was unable to be interviewed. Observation on 10/16/23 at 2:46 P.M., of Resident #10 found her fingernails continued to have a brown substance around them and she continued to have facial hair. Observation on 10/17/23 at 9:15 A.M., of Resident #10 found her fingernails continued to have a brown substance around them and she continued to have facial hair. Interview on 10/17/23 at 9:24 A.M., with State Tested Nursing Assistant (STNA) #360 verified Resident #10's fingernails were dirty and she had facial hair. STNA #360 reported she had been off but Resident #10 should have been shaven on her shower days and her nails cleaned whenever needed as Resident #10 would allow. STNA #360 stated she would make sure Resident #10 was cleaned up and shaven today. Observation on 10/17/23 at 2:28 P.M., of Resident #10 found her nails were cleaned and she had been shaven. Resident #10 nodded her head yes when she was asked if she was happy, she was cleaned up and shaven. Review of the policy titled, Fingernails/Toenails, Care of, revised 02/18 revealed the purpose of the policy was to keep nail beds clean and nails trimmed. Nail care included daily cleaning and regular trimming. Review of the policy titled, Activities of Daily Living, revised 10/22 revealed a resident who was unable to carry out activities of daily living will receive the necessary care and services to maintain good grooming and personal hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 4 of 21 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 10/19/2023 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, observations, staff interview, policy review, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to assess newly identified skin breakdown, notify the physician of skin breakdown, and implement treatments to aid in the healing of skin breakdown. This resulted in Actual Harm when Resident #28 was found to have an open area that was not assessed or treated for two days and then was assessed as a stage three pressure ulcer to the coccyx. Additionally, the facility failed to assess a newly identified skin breakdown for Resident #7, which placed the resident at risk for more than minimal harm that did not result in actual harm. This affected two (#7 and #28) of two residents reviewed for pressure ulcers. The facility identified 11 residents with pressure ulcers. The facility census 80. Residents Affected - Few Findings include: 1. Review of Resident #28's medical record revealed an admission date of 02/06/15. Diagnoses included malignant neoplasm of prostate, secondary malignant neoplasm of bone, major depressive disorder, type two diabetes mellitus, atrial fibrillation, chronic pain syndrome, and hypertensive heart disease with heart failure. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required the extensive assistance of two staff for bed mobility and transfers and required the extensive assistance of one staff for toileting. The resident was identified with one stage three pressure ulcer. Review of the skin care plan initiated 06/07/23 revealed the resident was at risk for skin breakdown. Interventions included routine turning and repositioning, routine toileting, pressure reducing cushion to chair, pressure reducing mattress on bed, weekly skin inspections, and treatments as ordered. The resident had refused placement of an air mattress. Review of a skin risk assessment dated [DATE] revealed the resident was at risk for skin breakdown. Review of a nurse's note dated 09/05/23 at 6:45 P.M., revealed the resident was observed with a pin sized hole on the sacrum that bleeds upon touch. The hospice nurse was notified and advised staff to place dry dressing to area until they assisted him in the morning. Review of the medical record revealed no wound assessment was completed and there was no documentation that the physician was notified. There were no physician orders for treatment. Review of a hospice handwritten note dated 09/06/23 revealed the resident had a coccyx pinhole wound and asked staff to let the facility skin team know. No wound assessment or physician notification was documented. Review of a skin and wound note dated 09/07/23 at 10:01 A.M., revealed the resident had a new stage three pressure ulcer to the coccyx. The wound measured 0.5 centimeter (cm) in length, 0.3 cm in width, and 0.4 cm in depth with 100% granulation tissue and scant amount of serosanguineous drainage. The wound edges were unattached. The resident was noted with blanchable erythema to the entire buttocks with scar tissue present. The nurse practitioner ordered to cleanse with wound cleanser, apply collagen to base of the wound and secure with hydrocolloid. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 5 of 21 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 10/19/2023 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 - Actual harm Residents Affected - Few Review of a physician order dated 09/09/23 revealed to cleanse wound to coccyx with wound cleanser, collagen, and hydrocolloid every Tuesday, Thursday, and Saturday. The order was discontinued on 09/18/23. Review of a physician order dated 09/19/23 revealed to cleanse wound with wound cleanser, apply calcium alginate with border foam daily. Review of the treatment administration record (TAR) dated 09/01/23 through 10/10/23 revealed there was no documentation that the initial treatment of a dry dressing was administered on 09/05/23 or 09/06/23. Also, there was no documentation of wound treatments being completed on 09/14/23, 09/21/23, 09/23/23, 09/30/23 and 10/05/23. Review of a skin and wound note dated 10/09/23 at 3:23 A.M., revealed the resident spent a good amount of time up in wheelchair during day and does not return to bed to offload as often as recommended. The resident's wound was stable. The wound measured 0.8 cm in length, 0.3 cm in width, 0.2 cm in depth with 100% granulation tissue and a small amount of serosanguineous drainage. The wound had unattached edges and the peri wound was macerated and intact. New orders to cleanse the wound with wound cleanser, apply triad paste to base of wound and leave open to air twice daily and as needed. Observation on 10/17/23 at 1:29 P.M., of wound care for Resident #28 with Registered Nurse (RN) #369 revealed Resident #28 had a pressure area to his coccyx. The area was round, less than one cm in length and width. The wound bed was 100% granulation tissue with no drainage and no odor. The surrounding skin was intact, red, and blanched. The resident had a pressure reducing cushion in his wheelchair and a pressure reducing mattress in place. Interview on 10/18/23 at 2:31 P.M., with the Director of Nursing (DON) and Unit Manager (UM) #401 revealed the resident had a pin size hole on the sacrum on 09/05/23. The DON and UM #401 revealed on 09/05/23 and 09/06/23 the wound was not assessed, and the physician was not notified. The DON and UM #401 revealed no treatment orders were in place until 09/07/23 when the wound was assessed as a stage three pressure ulcer to the coccyx. UM #401 also verified there was no documentation wound treatments were completed on 09/14/23, 09/21/23, 09/23/23, 09/30/23 and 10/05/23. 2. Review of Resident #7's medical record revealed an admission date of 06/21/21. Diagnoses included chronic kidney disease stage 3B, paraplegia, neuromuscular dysfunction of bladder, dementia, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment completed 08/11/23 revealed the resident had intact cognition. The resident required the extensive assistance of one staff for bed mobility, transfers, and toileting. The resident was at risk for pressure ulcers. The resident had no unhealed pressure ulcers. Review of the skin care plan initiated 03/17/22 revealed the resident was at risk for skin breakdown. Interventions included routine turning and repositioning, low air loss mattress to bed, pressure reducing cushion to chair, weekly skin inspection, and preventative skin care as ordered. Review of a skin risk assessment dated [DATE] revealed the resident was at risk for skin breakdown. Review of a weekly nursing summary dated 10/14/23 at 4:32 P.M., revealed the resident had a new open area to the sacrum and a treatment was in place. Review of the medical record revealed no wound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 6 of 21 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 10/19/2023 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 assessment was completed. Level of Harm - Actual harm Review of a physician order dated 10/14/23 revealed to cleanse the resident's sacrum with wound cleaner, apply silver alginate, and border foam daily. Residents Affected - Few Review of a skin and wound note dated 10/16/23 revealed the resident had a stage three pressure ulcer to the coccyx. The wound measured seven centimeters (cm) in length by 7.5 cm in width by 0.2 cm in depth. The wound was 100% granulation tissue with a moderate amount of serosanguineous drainage. The wound edges were attached. The surrounding skin was fragile with erythema. The resident was noted with chronic skin discoloration to the buttocks. The resident received new orders to cleanse with wound cleanser, apply calcium alginate to the base of the wound, secure with bordered foam dressing, change daily and as needed. Review of a physician order dated 10/17/23 revealed the treatment to the sacrum was changed to cleanse with wound cleaner, apply calcium alginate and border foam daily. Review of the medication administration record (MAR) dated 10/14/23 through 10/18/23 revealed the treatment to the sacrum was completed on 10/14/23, 10/15/23, and 10/16/23. There was no documentation of the wound being assessed until 10/16/23. Review of the treatment administration record (TAR) dated 10/14/23 through 10/18/23 revealed the treatment to the sacrum was completed on 10/17/23 and 10/18/23. Interview on 10/16/23 at 3:35 P.M., Unit Manager (UM) #401 revealed the resident had a recently healed wound that reopened over the weekend. UM #401 verified the wound found on 10/14/23 was not assessed until the nurse practitioner was in the facility on 10/16/23. Observation on 10/18/23 at 10:10 A.M., of wound care with UM #401 revealed the resident had a large pressure ulcer on his sacrum extending to the upper right and upper left buttocks. The wound bed was approximately 75% granulation tissue and 25% slough with no odor. The surrounding skin was excoriated, macerated, and discolored. The resident had a pressure reducing cushion in place for the wheelchair and an air mattress on the bed. Interview on 10/17/23 at 4:40 P.M., Regional Nurse Consultant (RNS) #439 revealed wounds should be assessed when found. Review of the policy titled Pressure Injury Prevention and Management, dated 2022, revealed the facility would establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions, and modifying the interventions as appropriate. Assessments of pressure injuries would be performed by a licensed nurse and documented in the medical record. The attending physician would be notified of the presence of a new pressure injury upon identification. Review of the policy titled, Wound Care, revised 10/2012, revealed the date, time and type of wound care given would be documented in the medical record. All assessment data including wound bed color, size, drainage, would also be documented in the medical record. Review of the NPUAP guidelines dated 2014 pages 70-71 at (https://npiap.com/general/custom.asp?page=2014Guidelines) revealed facilities should educate health professionals on how to undertake a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 7 of 21 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 10/19/2023 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominence. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. Event ID: Facility ID: 366188 If continuation sheet Page 8 of 21 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 10/19/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, staff interview, and review of policy, the facility failed to ensure resident's smoking materials were kept in a secured area by staff. This affected one resident (#36) of two residents reviewed for smoking. The facility census was 80. Findings include: Review of Resident #36's medical record revealed an admission date of 08/31/22. Diagnoses included paraplegia, osteomyelitis, major depressive disorder, seizures, adjustment disorder with anxiety, mild intellectual disabilities, and sleep disorder. Review of Resident #36's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #36 was cognitively intact. Resident #36 was totally dependent on staff for transfer. Resident #36 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #36 displayed verbal behavioral symptoms directed toward others and behavioral symptoms not directed toward others one to three days during the review period. Review of Resident #36's care plan revised 08/18/23 revealed supports and interventions for self-care deficit, behaviors of noncompliance, and smoking. Interventions for smoking included to complete smoking assessment quarterly and as needed, instruct resident about smoking risks and hazards about smoking cessation aides, instruct resident regarding the facility policy on smoking including designated locations, times, and safety concerns, notify nurse of any violations of smoking policy, and smoking materials to be kept with facility staff. Review of Resident #36's Behavioral Contract dated 03/07/23 revealed there was absolutely no smoking in rooms or the facility. Resident #36 was permitted to smoke outside per the facility policy. Resident #36 signed the agreement indicating he would be complaint with the smoking policy of the facility and would not smoke in his room and would not carry or smoke any illegal substances on the facility property. Review of Resident #36's Quarterly Smoking Review dated 07/05/23 revealed Resident #36 had his memory intact, had fine motor skills needed to securely hold a cigarette, was able to communicate the risks to smoking, able to light a cigarette safely, utilized an ashtray safely, was able to extinguish a cigarette safely, and smoked safely. Interview on 10/16/23 at 4:15 P.M., with Resident #36 revealed he was alert and aware. Resident #36 reported he smoked and went out to smoke whenever he wanted. Resident #36 reported he kept his smoking materials in his room, so they were always available to him. Resident #36 stated he did not have any designated smoking times. He reported he would take himself out to the smoking area whenever he wanted to smoke and would ring the bell to be let back in when he was done. Interview on 10/17/23 at 9:21 A.M., with State Tested Nursing Assistant (STNA) #360 verified Resident #36 smoked when he wanted to and kept his own cigarettes and lighter. Interview on 10/17/23 at 12:48 P.M., with Licensed Practical Nurse (LPN) #405 verified Resident #36 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 9 of 21 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 10/19/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few kept his own smoking materials and would take himself out to smoke whenever he wanted. LPN #405 reported Resident #36 would ring the bell when he was done smoking, and they would let him back into the facility. Interview on 10/18/23 at 11:30 A.M., with Resident #36 revealed he had his cigarettes and lighter in the front pocket of his sweatshirt at the time of the interview. Resident #36 reported when he did not have his smoking materials on his person, he would store them in the drawer next to his bed or in an empty tissue box on his bedside table which was up against the wall. Resident #36 demonstrated how he would put his cigarettes in the tissue box so one end was sticking up. Resident #36 again reported he did not have scheduled smoking times and would just go outside whenever he wanted to smoke. Review of the policy titled, Smoking Policy - Residents, revised 06/22 revealed all residents would be supervised during smoking. All smoking materials will be kept in a secure area by staff. Residents were not permitted to have any smoking related materials. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 10 of 21 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 10/19/2023 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, resident interview, review of physician orders, and policy review, the facility failed to ensure a urinary catheter anchor was in place for prevention of urinary catheter dislodgement. This affected one (#67) of one resident reviewed for urinary catheters. The facility identified five residents with urinary catheters. The facility census was 80. Findings include: Review of the medical record revealed Resident #67 had an admission date of 06/29/23. Diagnoses included benign prostatic hyperplasia, chronic kidney disease stage three, obstructive and reflux uropathy, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and malignant neoplasm of the prostate. Review of Resident #67's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #67 was cognitively intact. Resident #67 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #67 had an indwelling catheter at the time of the review. Review of the care plan last revised 06/29/23 revealed no interventions for a urinary catheter anchor. Review of a physician order dated 06/30/23 revealed the resident had orders for a Foley catheter for obstruction uropathy. Review of a physician order dated 06/30/23 revealed the resident had an order to secure Foley catheter tubing with Foley catheter anchor to resident's leg; change weekly on Sundays on nightshift and as needed to prevent dislodgement. Observation on 10/18/23 at 9:03 A.M., of Foley catheter care for Resident #67 with State Tested Nursing Assistant (STNA) #388 revealed a catheter anchor was not in place to secure the resident's urinary catheter tubing. Interview on 10/18/23 at 9:08 A.M., STNA #388 verified the resident's urinary catheter anchor was not in place and she would notify the nurse. STNA #388 revealed she was unaware of where the urinary catheter anchors were located. Interview on 10/18/23 at 9:09 A.M., Resident #67 revealed the urinary catheter anchor came off and staff had not replaced the anchor. Review of the policy titled, Catheter Care, Urinary, revised 09/2014, revealed for staff to ensure the catheter remained secured with a leg strap to reduce friction and movement at insertion site. Catheter tubing should be strapped to the resident's inner thigh. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 11 of 21 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 10/19/2023 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, staff interview and policy review, the facility failed to ensure a resident received nutritional supplements as ordered. This affected one resident (#67) of three residents reviewed for nutrition. The facility census was 80. Residents Affected - Few Findings include: Review of the medical record for Resident #67 revealed an admission date of 06/29/23. Diagnoses included protein calorie malnutrition, chronic kidney disease, adjustment disorder, osteoarthritis, and prostate cancer. Review of Resident #67's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #67 was cognitively intact. Resident #67 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #67 was totally dependent on staff for bathing. Resident #67 displayed no behavior during the review period. Resident #67 was independent with eating and was on a physician prescribed weight gain regimen. Review of Resident #67's care plan revised 08/09/23 revealed support and interventions for assistance with activities of daily living, and nutritional risk. Interventions for nutritional risk included honoring food preferences as much as possible and providing supplements as ordered. Review of Resident #67's physician orders revealed an order dated 08/10/23 for Ensure Clear three times a day. Review of Resident #67's Medication Administration Record (MAR) for August 2023, September 2023, and October 2023 revealed Resident #67's Ensure Clear was not provided for all three meals on 09/10/23, 09/11/23, 09/12/23, 09/13/23, 09/14/23, 09/16/23, 09/18/23, 09/20/23, 10/02/23, 10/03/23, 10/04/23, or 10/05/23. The missed supplements were not documented as refused. The documentation indicated the nurses notes should be reviewed for information. Corresponding nurses notes were not found for refusals. Interview on 10/16/23 at 9:44 A.M., with Resident #67 found him to be alert and aware. Resident #67 reported he was supposed to be receiving a nutritional supplement with every meal and he was not getting it all the time. Resident #67 reported due to his beliefs he had dietary restrictions and his supplement needed to be Kosher. He was prescribed Ensure Clear with all meals. Resident #67 reported he often did not get the supplement with his meals. Observation on 10/16/23 at 12:20 P.M., of Resident #67's meal tray delivery found no nutritional supplement provided. Interview on 10/16/23 at 12:25 P.M., with Resident #67 verified he was supposed to get his nutritional supplement with his meal, but he had not been provided one. Resident #67 reiterated his need for a dairy free supplement and his preference for mixed berry clear flavor. Interview on 10/16/23 at 12:31 P.M., with Unit Manager (UM) #401 verified Resident #67 had an order to receive Ensure clear three times a day and had not been provided one. UM #401 looked throughout (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 12 of 21 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 10/19/2023 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 0692 the unit searching in cupboards and refrigerators at the two nurses stations. No Ensure clear was found. Level of Harm - Minimal harm or potential for actual harm Interview on 10/16/23 at 12:34 P.M., with UM #401 verified there was not any of Resident #67's nutritional supplement available on the unit. Residents Affected - Few On 10/16/23 at 12:37 P.M., three unopened boxes of Boost Breeze were found in the large storage closet on the opposite end of the facility. A box was transported back to Resident #67's unit. On 10/16/23 at 12:40 P.M., Resident #67 was provided with his nutritional supplement. Interview on 10/19/23 at 10:50 A.M., with the Director of Nursing (DON) verified there was no corresponding notations as to why Resident #67 had not been provided his nutritional supplement as ordered in September and October of 2023. There were two notations in October 2023 indicating the supplement was on order. Review of the policy titled, Supplement Use, revised July 2020 revealed supplement use had the purpose to provide additional nutrition support to residents with identified risk conditions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 13 of 21 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 10/19/2023 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, medical record review, staff interview, review of the facility policy, and review of the manufacturer's guidelines, the facility failed to ensure proper hand hygiene was performed during food service on the third floor. This affected Resident #30 and had the potential to affect all residents on the third floor except Resident #44 who received no food from the kitchen. The facility identified 31 residents on the third floor. Additionally, the facility failed to ensure the dishwasher in the main kitchen washed dishes at the appropriate temperature. This had the potential to affect all residents in the facility except Resident #44 who received no food from the kitchen. The facility identified Resident #44 as the only resident in the facility who did not receive food from the kitchen. The facility census was 80. Findings include: 1. Observations beginning on 10/16/23 at 12:16 P.M., revealed Dietary Aide (DA) #321 with her bare hands taking food temperatures, using a pen to write food temperatures on a paper log, using a hot pad to place pans of food into the steamer, and then putting on food-safe gloves for meal service without washing her hands. DA #321 then touched the rolling cart, a coffee cup, a thickened coffee packet, and the coffee dispenser before returning to the tray line to wait to serve food. Upon returning to the tray line, DA #321 rested her hands on the biscuits in the tray while she waited to begin serving food. Interview on 10/16/23 at approximately 12:20 P.M., with DA #321 confirmed she touched several non-food items with her gloved hands before resting them on the biscuit. DA #321 proceeded to change her gloves without washing her hands. Continued observations during meal service revealed DA #321 serving chicken pot pie using the serving utensil, touching salad tongs, and picking up biscuits with a gloved hand to place on plates. Further observation revealed DA #321 wearing the same gloves and picking up a wrapped pack of hamburger buns, untwisting the tie holding the bag closed, reaching into the bag, taking out a bun, opening the bun with both gloved hands and placing it on a plate. DA #321 then picked up a hamburger patty with her gloved hand and placed it on the bun. DA #321 then walked to the refrigerator and placed her left hand on the frame of the refrigerator and used her right hand to pull open the handle. DA #321 picked up a plastic-wrapped block of sliced cheese and returned to the tray line where she opened the plastic and picked up a piece of cheese with her gloved hand and placed it on the burger patty. DA #321 continued to assemble the burger using a combination of her gloved hands and serving utensils. The burger was then given to Resident #30. Interview on 10/16/23 at 12:35 P.M., with DA #321 confirmed she touched multiple non-food items, including the refrigerator, and also touched ready-to-eat food (the hamburger) without changing her gloves and washing her hands. Interview on 10/16/23 at approximately 12:36 P.M., with Dietary Manager #325 confirmed DA #321 should wash her hands and change her gloves before touching ready-to-eat food. 2. Observation on 10/18/23 at approximately 10:25 A.M., revealed the dishwasher machine in the main kitchen in use and displaying a wash temperature of 142 degrees Fahrenheit (F) and a rinse temperature of 190 degrees F. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 14 of 21 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 10/19/2023 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 Interview on 10/18/23 at approximately 10:26 A.M., with DA #320 confirmed she had just run several loads through the dish machine. Further, DA #320 stated she had previously noted the washing temperature less than 150 degrees F and had mentioned it more than once to the representative from the chemical/service company who assured DA #320 that as long as the rinse temperature was above 180 degrees F, DA #320 did not need to worry about the wash temperature below 150 degrees F. Residents Affected - Many Interview on 10/18/23 at 10:30 A.M., with District Manager #440 confirmed the dish machine wash temperature read 142 degrees F and further confirmed the company policy was to maintain wash temperatures between 150-160 degrees F. Further, District Manager #440 confirmed the dish machine was a high temperature machine. Continued observations revealed staff put away dishes as they dried and did not rewash dishes in a properly functioning machine. Review of the policy titled, Ware washing, revised September 2017, revealed all dish machine water temperatures will be maintained in accordance with manufacturer recommendations for high temperature machines. Review of the manufacturer's guidelines for the dish machine, provided by District Manager #440, confirmed the minimum wash temperature should be 150 degrees F. Review of the policy titled Food: Preparation, revised September 2017, revealed all staff would use serving utensils appropriately to prevent cross contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 15 of 21 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 10/19/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, review of facility monitoring logs, Legionella Risk Assessment review, and review of the policy, the facility failed to ensure monitoring for Legionella was completed. This had the potential to affect all 80 residents in the facility. The facility census was 80. Residents Affected - Many Findings include: Review of the facility's undated Legionella Risk Assessment revealed the facility identified the incoming water supply and the building's hot and cold-water distribution systems as areas at risk for Legionella growth. Review of the facility monitoring logs dated January 2023 through October 2023 revealed rooms throughout the facility were monitored weekly and vacant rooms were identified. The log did not identify whether the sink or shower faucets were tested. The log did not include water temperatures. Interview on 10/18/23 at 4:13 P.M., with the Maintenance Director (MD) #413 revealed the monitoring logs for Legionella documented the vacant rooms in which he ran water. Further interview revealed no additional monitoring for Legionella, including water temperatures, was completed. Review of an undated facility documented titled Procedure for Legionella revealed the facility's census was reviewed weekly for vacant rooms. Vacant rooms were monitored for Legionella by running the water for five to ten minutes once weekly until the room was occupied. No guidance was provided regarding the running of sink faucets or shower heads, and whether hot or cold water should be running for five to ten minutes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 16 of 21 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 10/19/2023 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, review of monitoring logs, review of the medical record, and review of policy, the facility failed to ensure an antibiotic stewardship program was implemented to ensure infections and antibiotics were accurately being tracked. This had the potential to affect all 80 residents in the facility. The facility census was 80. Residents Affected - Many Findings include: Review of the Infection Surveillance Monthly Report (ISMR) dated August 2023 revealed line items for 45 identified infections. Further review revealed the log did not include the type of infection for 30 infections and did not include the signs and symptoms of the infection for 37 infections. Review of the ISMR dated September 2023 revealed line items for 64 identified infections. Further review revealed the log did not include the type of infection for 29 infections and did not include the treatment for 20 infections. Further, review of a line item for Resident #67 revealed an infection onset date of 09/25/23 of a urinary tract infection (UTI). No signs and symptoms were included in the log. Review of a line item for Resident #69 revealed an infection onset date of 09/26/23 of a urinary tract infection with signs and symptoms of altered mental status. Interview and concurrent review of the ISMR and medical records for Resident #67 and Resident #69 on 10/17/23 at 2:31 P.M. with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Regional Clinical Support #439 revealed Resident #67's UTI symptoms began 09/23/23, two days earlier than indicated on the log. Additionally, Resident #69's UTI symptoms including burning and itching (symptoms not captured on the log) beginning 09/23/23, three days earlier than indicated on the log. An ongoing interview at that time revealed the ADON assumed responsibility as the Infection Preventionist in July 2023. The ADON confirmed she was still learning how to complete the log accurately. Further, the ADON confirmed she was not completing an electronic assessment of each infection, per the facility's standard of practice, to ensure each infection was reviewed for antibiotic use as part of the antibiotic stewardship program. An ongoing interview at that time with Regional Clinical Support #439 confirmed some line items on the August and September 2023 logs reflected resolved incidents of infections and those line items remained on the log in error. Further interview at that time with the DON, ADON, and Regional Clinical Support #439 confirmed the ISMR log was incomplete, and the facility was not following their process for antibiotic stewardship surveillance. Review of the policy titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, revised 02/01/22, revealed the antibiotic surveillance tracking form would include twelve specific line items, including the date symptoms appeared, the name of the antibiotic, the start date of the antibiotic, and the identified pathogen (type of infection). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 17 of 21 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 10/19/2023 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the policy, the facility failed to ensure pneumococcal vaccines were offered to residents. This affected one (#1) of five residents reviewed for pneumococcal vaccines. The facility census was 80. Residents Affected - Few Findings include: Review of the medical record for Resident #1 revealed an admission date of 09/01/22, with diagnoses of hemiplegia and hemiparesis affecting the right dominant side and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition. Review of the Informed Consent for Pneumococcal Vaccine form signed 09/02/22 revealed Resident #1 gave permission to receive the pneumococcal vaccine and had not received a pneumococcal vaccine in the past five years. Interview on 10/17/23 at 12:12 P.M., with the Director of Nursing (DON) confirmed Resident #1 was eligible to receive a pneumococcal vaccine and the facility did not offer her one. Review of the policy titled, Pneumococcal Vaccine, revised February 2018, revealed all residents will be offered the pneumococcal vaccine within 30 days of admission to the facility unless medically contraindicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 18 of 21 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 10/19/2023 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, review of the Centers for Disease Control Prevention (CDC) guidelines, and review of the policy, the facility failed to ensure COVID-19 vaccines were offered to residents. This affected two (#1 and #44) of five residents reviewed for COVID-19 vaccination. The facility census was 80. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 09/01/22, with diagnoses of hemiplegia and hemiparesis and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition. Review of a form titled Coronavirus (COVID-19) Vaccination Acceptance Waiver revealed Resident #1 signed on 09/02/22 to accept the COVID-19 vaccine/booster. Review of Resident #1's vaccine record revealed no evidence of receiving a COVID -19 booster. 2. Review of the medical record for Resident #44 revealed an admission date of 04/06/22, with diagnoses of dementia and transient ischemic attack (stroke). Review of the quarterly MDS assessment dated [DATE] revealed Resident #44 had impaired cognition. Review of a form titled Coronavirus (COVID-19) Vaccination Acceptance Waiver revealed Resident #44 signed on 05/20/22 to accept the COVID-19 vaccine/booster. Review of Resident #44's vaccine record revealed no evidence of receiving a COVID -19 booster. Interview on 10/17/23 at 12:12 P.M., with the Director of Nursing (DON) confirmed Resident #1 and Resident #44 were eligible to receive a COVID-19 booster and were not offered one by the facility. Review of the Centers for Disease Control Prevention (CDC) guidelines for COVID-19 booster revealed the bivalent booster (for COVID-19 vaccination and to protect against variants Omicron BA.4 and BA.5) was available and recommended from 09/01/22 until 09/11/23. Websites accessed 10/12/23: https://www.cdc.gov/media/releases/2022/s0901-covid-19-booster.html and https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html. Review of the undated policy titled, SARS-CoV-2 Resident Vaccine revealed the facility would offer the COVID-19 vaccine and eligible booster doses to all residents who had no medical contraindications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 19 of 21 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 10/19/2023 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 - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, staff interview, and review of policy, the facility failed to ensure a resident's room was maintained in a clean, homelike environment. This affected one (#44) of two residents reviewed for a clean, homelike environment. The facility census was 80. Findings include: Review of the medical record for Resident #44 revealed an admission date of 04/06/22 with diagnoses of dementia and transient ischemic attack (stroke). Review of the quarterly MDS assessment dated [DATE] revealed Resident #44 had impaired cognition. Review of the physician orders for Resident #44 revealed he received no food by mouth and received nutrition via gastrostomy tube since 04/06/22. Observations on 10/16/23 at 9:23 A.M., on 10/17/23 at 8:37 A.M., and on 10/18/23 at 8:17 A.M., revealed Resident #44 lying in bed with a tube feeding bottle hanging on a pole next to his bed. The pump dispensing the tube feeding was running. The color of the tube feeding was tan. Resident #44's head of the bed was placed against a wall. The wall at the head of the bed had droplets and spots of dried tan/brown liquid covering approximately three feet wide and approximately three and a half feet high. Interview on 10/18/23 at 8:17 A.M., with Housekeeper #302 revealed she worked at the facility for approximately six months and was assigned to the third floor. Continued interview with Housekeeper #302 with concurrent observation of Resident #44's room confirmed dried brown spots and droplets were on the wall at the head of his bed. Housekeeper #302 stated the wall was like that since she began working at the facility and stated she had tried to clean it several times without success. Observation at that time, revealed Housekeeper #302 scrubbed the spots with routine cleaner and her rag and the spots remained on the wall. Housekeeper #302 stated she never tried a different cleaner or a more aggressive rag or sponge. Additionally, Housekeeper #302 stated she never reported her concerns with the spots to her supervisor or maintenance. Housekeeper #302 also stated Resident #44's family complained about the spots recently. Observation on 10/18/23 at 11:33 A.M., in Resident #44's room revealed the wall at the head of his bed was noticeably cleaner with only a few dried stained spots visible. Interview at that time with Resident #44 revealed no concerns regarding the spots in his room, he stated he could not see them when he was in bed. Further, Resident #44 was not aware of any concerns from his family about the wall. A subsequent interview on 10/18/23 at approximately 11:40 A.M., with Housekeeper #302 revealed she was unaware anyone entered Resident #44's room to clean the wall and was unaware the wall was noticeably cleaner. Interview on 10/19/23 at 3:28 P.M., with Maintenance Director #414 verified the dried spots and drips on Resident #44's wall were food based and not chemical. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 20 of 21 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 10/19/2023 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 Review of the policy titled Safe and Homelike Environment, revised February 2023, revealed housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366188 If continuation sheet Page 21 of 21