Resident #160 was admitted to the facility with orders for specialized Unna boot wound dressings to be changed on his bilateral lower extremities three times per week. The boots were supposed to be changed every Monday, Wednesday, and Friday.
They weren't.
Hospital discharge records from July 17 showed the resident had a follow-up appointment scheduled at a wound clinic on July 28. The facility's own care plan, dated July 18, acknowledged the resident had impaired skin integrity and included interventions for staff to complete wound treatment as ordered.
But wound care records revealed gaps. The resident's Unna boots were not changed on July 21 or July 23, despite physician orders requiring the treatments. When inspectors interviewed the administrator and a registered nurse on September 15, both confirmed the wound dressings should have been changed on those dates.
The missed appointment proved equally problematic. Scheduling personnel at the wound clinic confirmed to inspectors that Resident #160 was listed as a no-show for his July 28 follow-up appointment. The administrator and registered nurse acknowledged the resident was not transported to the appointment and that the missed visit was never documented in the resident's electronic health record.
The resident was cognitively intact and had not refused care, according to the inspection report.
Unna boots are specialized compression bandages used to treat venous leg ulcers and other lower extremity wounds. The zinc oxide-impregnated dressings help reduce swelling and promote healing when changed regularly as prescribed. Missing scheduled changes can allow wounds to worsen or become infected.
The facility's own wound management policy, dated May 20, 2024, stated that Majestic Care would "promote the treatment and healing of skin integrity impairment and optimize healing solutions." The policy appeared to exist on paper but not in practice for Resident #160.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to few residents. The deficiency was investigated under complaint number 2575262, suggesting someone reported concerns about the facility's wound care practices.
The inspection occurred on September 15, nearly two months after the missed treatments and appointment. During that time, Resident #160's wounds remained without the prescribed specialized care that his physician had ordered following hospitalization.
The administrator and registered nurse confirmed to inspectors that they were aware of the wound care orders and the missed appointment. Their acknowledgment suggested the facility knew about the lapses but had not corrected the problems or implemented systems to prevent similar failures.
Missing wound clinic appointments can have serious consequences for residents with chronic wounds. These specialized clinics often provide advanced treatments not available in nursing homes and monitor healing progress that determines whether more aggressive interventions are needed.
For Resident #160, the combination of missed dressing changes and the skipped wound clinic visit created a cascade of care failures. The hospital had specifically ordered the Unna boots and scheduled the follow-up appointment as part of his discharge plan, indicating the wounds required ongoing medical attention.
The facility's wound management policy promised to optimize healing solutions, but the reality for Resident #160 was different. His wounds went untreated on scheduled days, and his follow-up care was ignored entirely.
The inspection report does not indicate whether Resident #160's wounds worsened during the period of missed care or what ultimately happened to his condition. It also does not reveal whether other residents experienced similar lapses in wound care or missed medical appointments.
What it does show is a facility that failed to follow basic physician orders for a resident with serious wounds, despite having policies in place that promised proper wound management. The resident trusted the facility to provide the specialized care his doctor had prescribed.
Instead, he got empty appointment slots and unchanged bandages while his wounds waited for care that never came.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Majestic Care of Perrysburg from 2025-09-15 including all violations, facility responses, and corrective action plans.