Majestic Care of Perrysburg

Inspectors wroteBased on review of personnel files, staff interview and policy review, the facility failed to ensure newly hired staff were checked on the nurse aide registry to verify eligibility for employment prior to working with residents in the facility. This had the potential to affect all 52 residents in the facility. The facility census was 52.

Inspectors wroteBased on observation, staff interview, medical record review, policy review and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to implement and monitor Legionella control measures. This had the potential to affect all residents. Additionally, the facility failed to ensure enhanced barrier precautions (EBP) were implemented. This affected three (#1, #3 and #47) of three residents reviewed for transmission-based precautions (TBP). The facility census was 52.

Inspectors wroteBased on observation, staff and resident interviews, review of open and closed medical records, review of the facility water temperature logs and policy review, the facility failed to ensure shower water temperatures in the East Hall shower room were adequately warm. This affected four (#19, #24, #55 and #63) of four residents reviewed for comfortable and homelike environment. The facility identified 15 (#4, #11, #14, #26, #28, #29, #30, #31, #37, #39, #41, #47, #48, #50 and #56) additional residents who used the East-hall shower room. The facility census was 52.

Inspectors wroteBased on review of open and closed medical records, observations, resident and staff interviews and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments. This affected four (#29, #40, #55 and #62) of nine residents reviewed for MDS assessments. The facility census was 52.

Inspectors wroteBased on observation, medical record review, staff interviews and review of facility policy, the facility failed to ensure dependent residents received appropriate bathing, showers, grooming and fingernail care. This affected four (#14, #57, #62 and #63) of five residents reviewed for activities of daily living (ADLs). The facility census was 52.

Inspectors wroteBased on observation, open and closed medical record review, staff interview, resident interview, review of the facility elopement investigation files and review of facility policies, the facility failed to ensure adequate supervision was provided for residents assessed to be at risk for elopement. This affected one (#29) of one resident reviewed for elopement. Additionally, the facility failed to ensure smoking materials were properly stored. This affected one (#56) of two residents reviewed for smoking. Lastly, the facility failed to ensure neurological assessments were thoroughly completed following falls. This affected one (#63) of two residents reviewed for falls. The facility census was 52.

Inspectors wroteBased on medical record review, observations, staff interviews, review of an equipment compliance report, review of the user manual and review of facility policy, the facility failed to ensure emergency respiratory equipment was at the bedside for a tracheostomy. This affected one (#3) of one resident reviewed for tracheostomy care. Additionally, the facility failed to ensure physician orders for the administration of oxygen. This affected two (#30 and #40) of five residents reviewed for oxygen therapy. Lastly, the facility failed to ensure Bilevel Positive Airway Pressure (BIPAP) therapy was initiated as ordered and BIPAP machine maintenance was completed. This affected one (#4) of one resident reviewed for BIPAP therapy. The facility census was 52.

Inspectors wroteBased on observations, staff interview, and review of facility policy, the facility failed to store food in a safe and sanitary manner. This had the potential to affect 50 residents, Residents #3 and #37 received no food by mouth and thus received no food from the kitchen. The facility census was 52.

Inspectors wroteBased on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure resident respect and dignity was maintained. This affected one (#5) of three residents reviewed for respect and dignity. The facility census was 52.

Inspectors wroteBased on open and closed medical record review, staff interviews, and review of facility policy and procedures, the facility failed to ensure a baseline care plan was developed and provided to Resident #63's representative and further failed to ensure a baseline care plan for Resident #30 addressed the resident's care needs. This affected two (#63 and #30) of two residents reviewed for baseline care plans. The facility census was 52.

Inspectors wroteBased on medical record review, staff interview and review of facility policy, the facility failed to ensure non-pressure ulcer wound care was initiated timely upon admission and completed as ordered. This affected two (#1 and #55) of three residents reviewed for wound care. The facility census was 52.

Inspectors wroteBased on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure timely assessment and preventative interventions were implemented for a diabetic foot ulcer. This affected one (#47) of one resident reviewed for diabetic foot care. The facility census was 52.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy, the facility failed to ensure hemodialysis access sites were properly assessed and monitored. This affected one (#7) of one resident reviewed for dialysis care. The facility census was 52.

Inspectors wroteBased on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure medications were administered in accordance with physician orders and within prescribed time frames for five of 32 observed medications administered, resulting in a 15.63% medication error rate. This affected one (#47) of four residents reviewed for medication administration. The facility census was 52.

Inspectors wroteBased on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure insulin was administered in accordance with physician orders. This affected one (#47) of four residents reviewed for medication administration. The facility census was 52.

Inspectors wroteBased on observation, staff interview, medical record review and review of facility policy, the facility failed to ensure medications were not left unattended at bedside. This affected one (#4) of four residents reviewed for medication administration. The facility census was 52.

Inspectors wroteBased on closed medical record review, staff interviews and review of facility policy, the facility failed to ensure complete and accurate documentation in the medical record. This affected one (#59) of three residents reviewed for accurate medical records. The facility census was 52.

Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to ensure a call light was within reach. This affected one (#46) of six residents reviewed for call lights. The facility census was 55.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to report an allegation of an injury of unknown origin to the State Agency. This affected one (#31) of three residents reviewed for abuse. The facility census was 55. Review of the medical record for Resident #31 revealed an admission date of 03/27/25 with diagnoses including but not limited to anoxic brain damage, gastrostomy status, tracheostomy status, anxiety, cognitive communication deficit, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was rarely/never understood and had severe cognitive impairment. The resident was dependent on staff for all activities of daily living. Review of the care plan dated 11/10/25 revealed the resident had the potential/actual impairment to skin integrity. [...]

Inspectors wroteBased on record review, interview, and policy review, the facility failed to investigate a injury of unknown origin. This affected one (#31) of three residents reviewed for abuse. The facility census was 55.

Inspectors wroteBased 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.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure falls were thoroughly investigated to determine a root cause, documented in the medical record, and immediate interventions were put in place which were appropriate. This affected three (#5, #13, and #54) of three residents reviewed for falls. The facility census was 51.

Inspectors wroteBased on medical record review, observation, review of meal tickets, resident and staff interview, and policy review, the facility failed to ensure nutritional assessments were completed timely to determine dietary preferences and failed to ensure food preferences were honored. This affected two (#32 and #54) of four residents reviewed for nutrition. The facility census was 51.

Inspectors wroteBased on medical record review, staff interviews, wound clinic staff interview, and review of facility policy, the facility failed to ensure wound care treatments and follow-up appointments were completed as ordered. This affected three (#127, #134, and #160) of four residents reviewed for wound care. The facility census was 58.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, staff interview, review of pest control service records, and policy review, the facility failed to ensure the facility was free of ants. This affected five residents (#20, #25, #6, #41, #27) and the potential to affect an additional 13 residents (#2, #7, #8, #11, #13, #14, #18, #21, #22, #30, #32, #36, #47) residing on the 400 hall. The facility census was 46.

Inspectors wroteBased on review of a wound care treatment progress note, review of physician orders, observation, staff interview, and policy review, the facility failed to correctly identify the type and location of a wound. Additionally, the facility failed to ensure wound care treatments were completed per physician orders. This affected one (#30) of three residents reviewed for wound care. The facility identified seven residents requiring wound care management. The facility census was 46.

Inspectors wroteBased on review of the medical record, observation, staff interview, and policy review, the facility failed to ensure incontinence care was provided timely. This affected one (#30) of three residents reviewed for incontinence care. The facility census was 46.

Inspectors wroteBased on review of physician orders, review of the medication administration record, review of a pharmacy invoice, review of contingency medication supply records, staff interview and policy review, the facility failed to timely clarify physician orders and ensure medications were administered per physician orders. This affected one resident (#50) of three residents reviewed for medication administration. The facility census was 49.

Inspectors wroteBased on medical record review, observation, staff interviews, and review of facility policy, the facility failed to maintain resident dignity when dining. This affected five (#9, #21, #30, #32, and #51) of 13 residents observed during meals. The census was 50. Findings Include: 1. Review of the medical record revealed Resident #32 was admitted on [DATE]. Diagnoses included hypercholesterolemia, hypotension, generalized anxiety disorder (GAD), muscle weakness, other abnormalities of gait and mobility, difficulty in walking, cognitive communication deficit, personal history of COVID-19, and pain. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 03/06/24, for Resident #32 revealed the resident was severely cognitively impaired and required supervision or touching assistance with eating. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure resident wheelchairs were kept in a clean and sanitary manner. This affected three (#25, #32 and #43) of three residents reviewed for wheelchairs. The census was 50.

Inspectors wroteBased on medical record review, observation, staff and resident interview, and facility policy review, the facility failed to maintain proper infection control practices when providing care and services. This affected four (#18, #26, #37, and #48) of 14 residents observed receiving care and services from staff. The facility census was 50.

Inspectors wroteBased on review of resident funds accounts, fund balance notification documents, medical record review, and staff interview, the facility failed to ensure notifications of funds in excess of the Medicaid limit were followed up with timely notification and assistance to lower the fund balance. This affected three residents (#03, #24 and #27) of five reviewed for personal funds. The facility census was 50. Findings Include: 1. Review of Resident #03's personal funds account revealed a balance of $3,277.29 on 03/31/23, a balance of $3,349.38 on 06/30/23, a balance of $3,412.47 on 09/29/23, a balance of $3,502.56 on 12/29/23, and a balance of $3,529.60 on 03/26/24. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a comprehensive assessment was completed timely after a significant change in a resident's status. This affected one (#47) of 14 residents reviewed for assessments. The facility census was 50.

Inspectors wroteBased on medical record review, hospital documentation review, staff interview, and review of a facility policy, the facility failed to develop a care plan with appropriate interventions when a resident was readmitted to the facility with a new diagnosis following a hospitalization. This affected one resident (#42) of 14 residents reviewed for care plans. The facility census was 50.

Inspectors wroteBased on medical record review, staff interview, and review of a facility policy, the facility failed to ensure laboratory tests were completed as ordered by the physician. This affected one (#42) of six residents reviewed for laboratory testing. The facility census was 50.

Inspectors wroteBased on medical record review, hospital documentation review, and staff interview, the facility failed to ensure diagnostic services were provided as ordered. This affected one resident (#42) of 14 residents reviewed for care and services. The facility census was 50.

Inspectors wroteBased on review of staffing schedules, review of daily posted staffing information, staff interview, and policy review, the facility failed to ensure a Registered Nurse (RN) was present in the facility eight hours per day, seven days per week. This had the potential to affect all residents. The facility census was 52.

Inspectors wroteBased on review of the medical record, review of a risk alert document, review of fall investigations, observation, interview, and policy review, the facility failed to ensure a thorough investigation was completed to determine how a resident exited the facility through a locked door in the memory care unit. This affected one (Resident #21) of three residents reviewed for elopement. The facility identified five residents (#21, #34, #40, #50 #51) at risk for elopement. Additionally, the facility failed to complete a thorough falls investigation and implement new fall prevention interventions to potentially prevent additional falls for one resident. This affected one (Resident #27) of three residents reviewed for falls. The facility census was 52.

Inspectors wroteBased on medical record review, staff interview, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure pneumococcal vaccines were offered to residents per CDC recommendations. This affected four (#40, #43, #51, and #54) of five residents reviewed for pneumococcal vaccination. Additionally, the facility failed to provide vaccination education to one (#11) of five residents reviewed for pneumococcal vaccinations. The facility census was 56.

Inspectors wroteBased on medical record review, staff interview, review of facility policy, and review of a Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure COVID-19 vaccination booster doses were offered to residents. This affected two (#11 and #51 ) of five residents reviewed for COVID-19 vaccination booster status. The facility census was 56.

Inspectors wroteBased on review of staff schedules, review of facility documentation, staff interview, and review of facility policy, the facility failed ensure registered nurse (RN) services were utilized at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 53 residents residing in the facility.

Inspectors wroteBased on observation, staff interview, medical record review, and review of manufacturer instructions, the facility failed to ensure medications were administered per manufacturer instructions, resulting in a medication error rate of five percent (%) or greater. There were three medication errors out of 31 opportunities, resulting in a medication error rate of 9.68%. This affected two (Residents #11 and #48) of four residents reviewed for medication administration. The facility census was 53.

Inspectors wroteBased on observations, staff interviews, medical record reviews, and review of manufacturer instructions, the facility failed to ensure the administration of insulin medications were provided in accordance with instructions for use which resulted significant medication errors and potential dosage errors. This affected two (Residents #11 and #48) of four residents reviewed for medication administration. The facility census was 53.

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to serve meals in a dignified manner by serving meals on disposable dishware and cutlery. This had the potential to affect all residents except for Residents #26, #27, #30, #36, #39, #40 who did not identify dignity concerns and Residents #197 and #198 identified by the facility as residents who did not receive food from the kitchen (did not eat by mouth). The facility census was 47.

Inspectors wroteBased on review of Resident Trust Account Authorizations, facility policy, and staff interview, the facility failed to ensure residents had reasonable access to personal funds. This affected Residents #2, #3, #4, #7, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #21, #22, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, and #43 identified by the facility as having Resident Trust Accounts. In addition, the facility failed to have signed witnessed authorizations for two (#15 and #20) of five residents reviewed for personal funds. The facility census was 47.

Inspectors wroteBased on medical record review, staff interview, and review of policy for wound care, policy for falls, and policy for neurological assessments, the facility failed to provide non-pressure wound care as ordered for two (Residents #27 and #45) of three residents reviewed for wound care, failed to conduct neurological assessments for two (Residents #15 and #42) of three residents reviewed for falls, and failed to complete post fall assessments for one (Resident #42) of three residents reviewed for falls. The facility census was 47.

Inspectors wroteBased on observation, medical record review, staff interview, review of Safety Data Sheets, and review of facility policy, the facility failed to secure potentially hazardous chemicals on the secured memory care unit. This affected 12 (#1, #3, #4, #5, #10, #11, #15, #16, #17, #21, #37, and #43) residents identified by the facility as being cognitively impaired, independently mobile, and residing on the memory care unit. In addition, the facility failed to implement fall interventions as care planned for one (#42) resident of three residents reviewed for falls. The facility census was 47.

Inspectors wroteBased on observation and staff interview, the facility failed to have sufficient dietary staff to perform all dietary functions, including dish washing. This had the potential to affect 45 out of 47 residents who receive meals from the kitchen, the facility identified two (#197 and #198) residents who receive no nutrition from the kitchen. The facility census was 47.

Inspectors wroteBased on review of the facility menu, review of facility documents, observations and resident and staff interview, the facility failed to follow established menus, failed to post menus, substitutions, and alternative menu selections, and failed to maintain a substitution log. This had the potential to affect 45 out of 47 residents who receive meal trays, the facility identified two residents (#197 and #198) residents who receive no nutrition from the kitchen. The facility census was 47.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to serve meals at appropriate temperatures. This had the potential to affect 45 out of 47 residents who received meal trays, the facility identified two (#197 and #198) residents who did not receive nutrition from the kitchen. The facility census was 47.

Inspectors wroteBased on observation of alternative menu options, resident and staff interview, and review of facility policy, the facility failed to offer residents preferred meal options. This had the potential to affect 45 out of 47 residents who received meal trays, the facility identified two (#197 and #198) residents who received no nutrition from the kitchen. The facility census was 47.

Inspectors wroteBased on observation and staff interview, the facility failed to use appropriate hand hygiene when preparing meals. This had the potential to affect 45 out of 47 residents who receive meals from the kitchen, except for two (#197 and #198) residents, identified by the facility as receiving no food by mouth. The facility census was 47.

Inspectors wroteBased on medical record review, family and staff interview, and review of facility policy, the facility failed to notify the physician when an ordered treatment could could not be provided. This affected one resident (#24) out of one resident reviewed for physician notification. The facility census was 47.

Inspectors wroteBased on record review, observation, resident and family interviews and staff interview the facility failed to ensure resident equipment including, intravenous (IV) poles and wheelchairs, were in safe working order. This affected two (#45 and #24) residents, out of 28 residents reviewed for safe environment. The facility census was 47.

Inspectors wroteBased on staff interview, record review, and review of facility policy, the facility failed to provide discharge documentation to another facility upon discharge of a resident. This affected one resident (#47) of one reviewed for discharge. The facility census was 47.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide written transfer notification to residents transferred to the hospital. This affected two (#197 and #49) of three residents reviewed for transfer notices. The facility census was 47.

Inspectors wroteBased on resident interview, record review, staff interview, review of the admission agreement, and review of facility policy, the facility failed to provide written bed hold notices upon transfer from the facility. This affected three (#45, #49, and #197) of three residents reviewed for hospitalization. The facility census was 47.

Inspectors wroteBased on record review, resident interview, staff interview, and review of facility policy, the facility failed to develop comprehensive care plans for ostomy wound care, pressure ulcers, and oxygen. This affected two residents (#25 and #45) out of 28 residents reviewed for care plans. The facility census was 47.

Inspectors wroteBased on staff interview, record review, and review of the facility policy, the facility failed to have complete a discharge summary upon discharge of a resident. This affected one resident (#47) out of one resident reviewed for discharge. The facility census was 47. Review of the medical record for Resident #47 revealed he was admitted on [DATE] and discharged to another facility on 01/14/22. Diagnoses included vascular dementia with behavioral disturbance, schizophrenia, and type 2 diabetes mellitus. Review of the comprehensive minimum data set (MDS) dated [DATE] revealed Resident #47 had impaired cognition. He required limited assistance of one person for bed mobility, supervision of one person for transfers and walking, and required extensive assistance of two people for toileting and hygiene. A review of the medical record for Resident #42 revealed no discharge summary. [...]

Inspectors wroteBased on resident and staff interviews, medical record review, review of the facility's shower schedule, and review of policy for personal care, the facility failed to provide showers as scheduled for one resident (Resident #27) of one resident reviewed for activities of daily living (ADL). The facility census was 47.

Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to complete wound assessments for one (Resident #45) and failed to provide pressure wound treatments for one (Resident #18) out of three residents reviewed for wound care. The facility census was 47.

Inspectors wroteBased on medical record review, review of a dietary meal ticket, staff interview, and review of facility policy, the facility failed to ensure residents were provided with physician ordered diets. This affected one (#23) of one residents reviewed for nutrition. The facility census was 47.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to timely review pharmacy recommendations. This affected three (#15, #24, and #28) of five residents reviewed for unnecessary medications. The census was 47.

Inspectors wroteBased on medical record review, observation, resident and staff interview and review of the facility policy, the facility failed to accurately document the administration of oxygen. This affected one (#25) of one reviewed for oxygen use. The facility census was 47.