Majestic Care Of Perrysburg

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

cognitively intact and did not refuse care.Review of the hospitalization after visit summary dated 07/17/25 for Resident #160 revealed wound care orders for Unna boots (wound dressing wraps) to bilateral lower extremities to be changed on Mondays, Wednesdays, and Fridays. Further review of the hospitalization

after visit summary revealed he had a scheduled follow-up appointment at a wound clinic on 07/28/25.Review of the care plan dated 07/18/25 for Resident #160 revealed he had impaired skin integrity.

The interventions included for staff to complete wound treatment as ordered.Review of physician orders and the July TAR for Resident #160 revealed wound care orders dated 07/25/25 for Unna boots to bilateral lower extremities to be changed on Mondays, Wednesday, and Fridays. Further review of the TAR revealed wound care was not completed on 07/21/25 and 07/23/25. Interview on 09/15/25 at 9:52 A.M. with the Administrator and Registered Nurse (RN) #101 confirmed Resident #160 was admitted with orders for Unna boots to his bilateral lower extremities to be changed on Mondays, Wednesdays, and Fridays. Further

interview confirmed the Unna boots should have been changed on 07/21/25 and 07/23/25 but were not.Interview on 09/15/25 at 10:01 A.M. with Scheduling Personnel at the wound clinic confirmed Resident #160 was scheduled for a wound care follow-up appointment on 07/28/25 and was listed as being a no show for that appointment.Interview on 09/15/25 at 10:40 A.M. with the Administrator and RN #101 confirmed Resident #160's follow-up appointment at the wound clinic on 07/28/25 was not documented in

the resident's electronic health record and the resident was not taken to the appointment. Review of facility policy titled, [NAME] Care Wound Management Policy, dated 05/20/24, revealed the facility would promote

the treatment and healing of skin integrity impairment and optimize healing solutions. This deficiency represents non-compliance investigated under Complaint Number 2575262.

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Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Majestic Care of Perrysburg

28546 Starbright Blvd Perrysburg, OH 43551

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** Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure pressure ulcer treatments were completed as ordered. This affected two (#134 and #140) of four residents reviewed for wound care. The facility census was 58.Findings include:1. Review of the medical record for Resident #134 revealed he was admitted on [DATE REDACTED] with diagnoses that included disorder of lipoprotein, myelodysplastic syndrome (disorder affecting bone marrow), and non-pressure chronic ulcer of the right heel and midfoot with the fat layer exposed. Review of the admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #160 was moderately cognitively impaired, and he did not refuse care.Review of the current care plan for Resident #134 revealed he had impaired skin integrity. The interventions included wound treatment as ordered.Review of the physician orders and treatment administration records (TAR) for Resident #134 revealed orders beginning on 06/21/25 for daily wound care to a pressure ulcer on his right foot to cleanse with normal saline, apply collagen, cover with an abdominal dressing, wrap with Kerlix (fluffy gauze), and secure with tape. Further review of the TARs revealed wound care was not completed on 06/06/25, 06/15/25, 06/16/25, 06/22/25, 06/23/25, 07/01/25, 07/12/25, 07/26/25, 08/01/25, 08/02/25, 08/05/25, and 08/11/25.2. Review of the medical record for Resident #140 revealed he was admitted on [DATE REDACTED] with diagnoses that included traumatic brain injury, intracranial abscess and granuloma, tracheostomy, gastrostomy, and acquired absence of part of the head and neck.Review of the quarterly MDS assessment dated [DATE REDACTED] revealed Resident #140 was unable to be assessed cognitively due to a traumatic brain injury, and he did not refuse care.Review of the care plan dated 03/19/25 for Resident #140 revealed he had a pressure injury to his right outer foot. The interventions included to administer treatments as ordered.Review of the current care plan for Resident #140 revealed he had a pressure injury to his left foot. The interventions included to provide wound care per treatment orders.Review of the physician orders and TARs for Resident #140 revealed orders beginning on 12/17/24 for daily wound care to his left foot to cleanse with normal saline, pat dry, apply skin prep (a protective barrier), and leave open to air. Further

review of the TARs revealed wound care was not completed on 03/03/25, 03/04/25, or 03/22/25. Review of

the physician orders and TARs for Resident #140 revealed orders beginning on 12/18/24 for daily wound care to his right outer foot to cleanse with normal saline, pat dry, apply Medihoney and calcium alginate, cover with abdominal dressing, and wrap with Kerlix. Further review of the TARs revealed wound care was not completed on 03/03/25.Review of the physician orders and TARs for Resident #140 revealed orders beginning on 03/21/25 for twice daily wound care to his right outer foot to cleanse with normal saline, pat dry, and apply skin prep. Further review of the TARs revealed wound care was not completed on 03/22/25 and 03/23/25. Review of the physician orders and TARs for Resident #140 revealed orders beginning on 09/11/25 for daily wound care to his left foot to cleanse with normal saline, pat dry, apply skin prep, and cover with border gauze. Further review of the TARs revealed wound care was not completed on 09/12/25.

Interview on 09/11/25 at 4:10 P.M. and 5:20 P.M. with the Director of Nursing (DON) confirmed wound care was not completed for Resident #134's pressure ulcer on 06/06/25, 06/15/25, 06/16/25, 06/22/25, 06/23/25, 07/01/25, 07/12/25, 07/26/25, 08/01/25, 08/02/25, 08/05/25, and 08/11/25, and for Resident #140 on 03/03/25, 03/04/25, 03/22/25, 03/23/25, and 09/12/25.Review of facility policy titled, [NAME] Care Wound Management Policy, dated 05/20/24, revealed the facility would promote the treatment and healing of skin integrity impairment and optimize healing solutions. This deficiency represents non-compliance investigated under Complaint Number 2575262.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet