Federal inspectors responding to a complaint found the 51-bed facility failed to develop specific care plans addressing where residents wanted to go after their stays ended. The violations affected residents who remained at the facility for weeks without anyone determining their preferences for future living arrangements.
Resident 53 arrived on June 2nd with multiple conditions including congestive heart failure, chronic pain, and major depression. Despite being cognitively intact, the resident's care plan contained only generic language about social services assisting with discharge planning.
The plan lacked any evidence the facility had determined whether the resident wanted to return to the community. After two months, Resident 53 was discharged on August 1st.
Resident 54's case was more stark. The patient arrived September 11th with pneumonia, kidney transplant status, and end-stage renal disease requiring ongoing medical management. Inspectors found no specific discharge care plan had ever been initiated for this cognitively intact resident.
After just over a month, Resident 54 was discharged on October 13th without the facility having documented discharge preferences or goals.
MDS Nurse 122 told inspectors during an October 23rd interview that care plans are updated quarterly and when significant changes occur during interdisciplinary team meetings. The nurse confirmed that different departments create their own care plans, with dietary, social services, and activities handling separate planning.
When asked specifically about the two residents, MDS Nurse 122 verified neither had completed discharge care plans that addressed their specific goals for discharge location.
The facility's own policy requires comprehensive person-centered care plans that include "the resident's goals for admission, desired outcomes, and preferences for future discharge." The policy, revised in May 2024, mandates resident-specific interventions that reflect individual needs and preferences.
Federal regulations require nursing homes to develop complete care plans with measurable objectives and timeframes. For discharge planning, this means determining not just medical readiness but where residents want to live and what support they need to get there.
The failure becomes more significant given both residents' cognitive abilities. Unlike patients with dementia who may struggle to express preferences, both residents could have participated in planning their futures.
Resident 53's two-month stay stretched from early June through August without documented discussions about discharge goals. The resident's conditions - hypertension, heart failure, chronic pain, and depression - required ongoing management but didn't necessarily preclude community living with proper support.
Resident 54's case involved more complex medical needs given the kidney transplant status and end-stage renal disease. Yet the facility never initiated specific discharge planning despite the resident's cognitive capacity to participate in such decisions.
The inspection occurred as part of a complaint investigation, suggesting someone raised concerns about the facility's discharge planning practices. Federal inspectors classified the violations as causing minimal harm or potential for actual harm to residents.
Without proper discharge planning, residents may remain in institutional care longer than necessary or be discharged to inappropriate settings without adequate preparation. The process requires coordination between medical teams, social workers, families, and community resources.
For cognitively intact residents, the planning should involve their direct participation in choosing discharge destinations and understanding what services they'll need. This becomes particularly important for residents with chronic conditions requiring ongoing medical management in community settings.
The facility serves 51 residents, making the two affected residents represent about 4% of the census. However, inspectors reviewed only seven residents' care plans, meaning the violation rate among those examined was nearly 30%.
Both residents were ultimately discharged, but without documented evidence their preferences guided the process. The inspection report doesn't indicate where they went or whether they received appropriate community supports.
The violations represent a breakdown in the interdisciplinary approach nursing homes are required to use. While MDS Nurse 122 described departments creating separate care plans, federal requirements call for coordinated planning that addresses residents' comprehensive needs.
Majestic Care of Perrysburg must now submit a plan of correction addressing how it will ensure all residents receive proper discharge planning that reflects their individual goals and preferences for future living arrangements.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Majestic Care of Perrysburg from 2025-10-23 including all violations, facility responses, and corrective action plans.