Majestic Care Of Perrysburg

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure care plans were implemented and contained resident specific goals and preferences regarding discharges. This affected two (#53 and #54) of seven residents reviewed for care plans. The facility census was 51.Findings include:1.

Review of the medical record for Resident #53 revealed an admission date of 06/02/25 and discharge date of 08/01/25. Diagnoses included but were not limited to hypertension, congestive heart failure, chronic pain disorder, and major depressive disorder.Review of the Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #53 was cognitively intact.Review of the care plan dated 06/03/25 revealed Resident #53's discharge plan included interventions for social services to assist with discharge planning. The care plan was not specific to the resident's preference and potential for future discharge and lacked evidence the facility determined the resident's desire to return to the community. 2. Review of the medical record for Resident #54 revealed an admission date of 09/11/25 and discharge date of 10/13/25. Diagnoses included but were not limited to pneumonia, kidney transplant status, end stage renal disease, and anemia.Review of the MDS assessment dated [DATE REDACTED] revealed Resident #54 was cognitively intact.Review of the care plan dated 09/11/25 revealed no specific care plan to address Resident #54's discharge planning was initiated.Interview on 10/23/25 at 11:16 A.M. with MDS Nurse #122 revealed care plans are updated at a minimum of quarterly, with significant changes, new orders, falls, and other events during interdisciplinary team (IDT) meetings. MDS Nurse #122 stated the dietary, social services, and activity departments completed their own care plans. MDS Nurse #122 verified Resident #53 and Resident #54 did not have a completed discharge care plan that was resident specific as to the goal of discharge location. Review of policy titled, Comprehensive Care Plan, revised on 05/16/24, revealed the purpose was to develop and implement a comprehensive person-centered care plan for each resident/patient, consistent with resident/patient rights, that includes measurable objectives and timeframes to meet a resident's/patient's medical, nursing, and mental and psychosocial needs that are identified in the resident's/patient's comprehensive assessment. The comprehensive care plan will describe, at a minimum, the following: the resident's/patient's goals for admission, desired outcomes, and preferences for future discharge and resident/patient specific interventions that reflect the resident's/patient's need and preferences and align with the resident's/patient's cultural identity, as indicated.This deficiency represents non-compliance investigated under Complaint Number 2630192.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

10/23/2025

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 0689 Level of Harm - Minimal harm or potential for actual harm

experiences a fall, the facility will assess the resident, complete a post-fall assessment, complete an incident report, notify the physician and family, review the resident's care plan and update as indicated, document all assessments and actions, and obtain witness statements in the case of injury.This deficiency represents non-compliance investigated under Complaint Number 2630192.

Residents Affected - Few

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

Event ID:

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

10/23/2025

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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

mention of not serving beef.Interview on 10/23/25 at 1:45 P.M. with the Administrator revealed dietary preferences are put into the meal suite and are sent to the kitchen. The Administrator stated when she interviewed Resident #32 he verbally told her he did not like pork and did not mention not liking beef. The Administrator verified it was not documented anywhere and his meal tickets contained the notation for no pork or beef. The Administrator verified no nutritional interview was completed for Resident #54 upon admission to determine food preferences. The Administrator stated sometimes the residents think they are getting pork but it was not pork. For example, they served turkey sausage on 10/22/25 and the residents thought it was pork sausage.Review of the policy titled, Nutrition Assessment, dated 08/01/25, revealed each resident/patient will be interviewed within 72 hours of admission to determine food and meal preferences as well as to assess nutrition status and factors that may put the resident/patient at risk for altered nutrition. A registered dietician will assess the nutritional status of each resident/patient at a minimum at time of admission, with significant change in condition, and annually. Food allergies/intolerances will be confirmed and entered into the electronic medical record. The resident's/patient's nutrition care plan will be updated with each MDS assessment and as needs/interventions change.This deficiency represents non-compliance investigated under Complaint Number 2630192.

Event ID:

Facility ID:

If continuation sheet