Inspection·August 12, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Review of the medical record for Resident #50 revealed an admission date of 06/30/24 and a discharge date d of 07/25/24. Diagnoses included cirrhosis of the liver, hepatic encephalopathy, hypertension, peripheral vascular disease, diabetes mellitus type two, fibromyalgia and bipolar disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had cognitive impairment. Review of the hospital discharge medication orders dated 06/30/24 revealed Resident #50 was ordered pregabalin (Lyrica) 50 milligrams (mg) three times a day for pain and ezetimibe 10 mg daily for hyperlipidemia. The resident had orders for lactulose 20 milligrams for liver disease with no frequency listed. Review of the physician orders dated 06/30/24 revealed Resident #50 had orders for pregabalin 50 mg three times a day by mouth and ezetimibe 10 mg daily. The order for the lactulose was not clarified until 07/02/24, when the physician ordered lactulose 20 mg two times a day. Review of the medication administration record (MAR) from 06/30/24 through 07/25/24 revealed Resident #50 was not administered the lactulose and ezetimbe until 07/02/24. The resident was not administered the pregabalin on 06/30/24 and only administered pregabalin one time on 07/01/24. Review of the contingency medication supply list revealed the facility had pregabalin available for administration. Review of the pharmacy invoice dated 07/01/24 revealed the ezetimibe was received by the facility on 07/01/24. Interview on 08/12/24, beginning at 10:02 A.M., with the Director of Nursing (DON) and the Regional Clinical Nurse (RCN) #206 revealed Resident #50's physician orders for lactulose should have been (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 2 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 08/12/2024 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)