Inspection·December 7, 2023

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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, 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. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 09/20/22. Diagnoses included end stage renal disease and acquired absence of other organs. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 10/08/23, revealed Resident #11 had intact cognition. Review of the immunization record in the electronic medical record (EMR) revealed Resident #11 refused the pneumococcal vaccine. No date of refusal was documented in the record and there was no evidence the facility provided education to Resident #11 on the risks and benefits of pneumococcal vaccination. 2. Review of the medical record for Resident #40 revealed an admission date of 08/07/23. Diagnoses included dementia and chronic obstructive pulmonary disease. Review of the quarterly MDS assessment, dated 11/17/23, revealed Resident #40 had impaired cognition. Review of the immunization record in the EMR revealed no documentation related to Resident #40's pneumococcal vaccination status. Review of CDC recommendations for pneumococcal vaccine timing for adults, dated 02/16/22, revealed, based on the resident's age, Resident #40 should have been offered one dose of the pneumococcal 15-valent conjugate vaccine (PCV 15) or PCV20 vaccine. 3. Review of the medical record for Resident #43 revealed an admission date of 11/03/23. Diagnoses included dementia and bipolar disorder. Review of the comprehensive MDS assessment, dated 11/10/23, revealed Resident #43 had impaired cognition. (continued on next page) 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 Page 1 of 3 Event ID: 365624 Printed: 05/15/2026 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 365624 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 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)