State inspectors found Majestic Care of Perrysburg failed to complete ordered daily wound treatments for residents with serious medical conditions, documenting missed care dates spanning from March through September.
Resident 134 arrived at the facility with multiple diagnoses including a bone marrow disorder and a non-pressure chronic ulcer on his right heel and midfoot with fat layer exposed. Despite physician orders for daily wound care beginning June 21, staff skipped treatments on 12 separate days through August 11.
The ordered treatment required staff to cleanse the wound with normal saline, apply collagen, cover with an abdominal dressing, wrap with fluffy gauze, and secure with tape. Records show no wound care occurred on June 6, June 15, June 16, June 22, June 23, July 1, July 12, July 26, August 1, August 2, August 5, and August 11.
Resident 134 was moderately cognitively impaired but did not refuse care, according to his admission assessment.
The second resident affected had sustained a traumatic brain injury so severe he could not be assessed cognitively. Resident 140 arrived at Majestic Care with multiple conditions including intracranial abscess, tracheostomy, gastrostomy, and acquired absence of part of his head and neck.
This resident developed pressure injuries on both feet that required different treatment protocols. For his left foot wound, physicians ordered daily cleansing with normal saline, patting dry, applying a protective barrier, and leaving open to air. Staff failed to complete this treatment on March 3, March 4, and March 22.
His right outer foot required more intensive care. Initially, orders called for daily cleansing with normal saline, patting dry, applying Medihoney and calcium alginate, covering with abdominal dressing, and wrapping with gauze. Staff missed this treatment on March 3.
By March 21, physicians changed the right foot treatment to twice daily wound care with normal saline cleansing, patting dry, and applying the protective barrier. Records show no care on March 22 and March 23.
The most recent missed treatment occurred September 12, when staff failed to complete newly ordered daily care for Resident 140's left foot wound that required cleansing, drying, protective barrier application, and covering with border gauze.
The Director of Nursing confirmed all the missed treatments during interviews with state inspectors on September 11. The DON acknowledged wound care was not completed for Resident 134 on the 12 documented dates and for Resident 140 on five separate occasions.
Majestic Care's own wound management policy, dated May 20, states the facility would "promote the treatment and healing of skin integrity impairment and optimize healing solutions."
The facility operated with 58 residents during the inspection period. State investigators reviewed wound care for four residents total and found treatment failures affecting two of them.
Pressure ulcers develop when sustained pressure reduces blood flow to tissue, causing skin and underlying tissue to break down. The wounds can become infected and lead to serious complications, particularly in residents with compromised immune systems or other medical conditions.
The inspection occurred following a complaint, assigned number 2575262. State regulators classified the violation as causing minimal harm or potential for actual harm.
Both residents had care plans specifically addressing their wound care needs. Resident 134's plan included "wound treatment as ordered" as an intervention for his impaired skin integrity. Resident 140's care plan called for administering treatments as ordered and providing wound care per treatment orders.
The missed treatments occurred despite physician orders that specified exact procedures, frequencies, and materials needed for proper wound care. Treatment administration records documented the gaps in care across multiple months.
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.