Inspection·March 5, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include 1. Review of the medical record revealed Resident #21 had an admission date of 06/09/23. Diagnoses included Alzheimer's disease, chronic pain, and difficulty walking. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of an elopement evaluation dated 12/09/23 revealed the resident was at risk for elopement. Review of a nurses note dated 01/17/24 at 8:02 P.M. revealed the nursing assistant reported Resident #21 had opened the back exit door in the memory care unit and was attempting to walk through the back parking lot. The resident remained in clear view of staff at all times and was redirected back to her room without incident. A head-to-toe assessment was completed and the resident denied pain. The resident was moved closer to the nursing station for closer monitoring. There was no documentation how the resident was able to open the locked exit door. Review of a facility Risk Alert document dated 01/18/24 revealed an elopement event occurred on 01/17/24 at 5:35 P.M. Nurses and nursing assistants were attending to a resident when the nursing assistants saw Resident #21 open the exit door at the end of the hall and walk outdoors. The nursing assistant took off towards the resident in the back parking lot to bring the resident back in the building. The resident was brought back inside immediately, witness statements obtained, a head to toe assessment was completed, and a pain assessment was completed. The Administrator, Resident #21's Power of Attorney (POA), and the physician were notified. The resident was moved to a room closer to nurses' station further from the exit door for closer supervision. Further review of the facility investigation and witness statements revealed no documentation how the resident was able to exit the facility through a door which should have been locked. (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 4 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 03/05/2024 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)