Inspection·December 19, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Few Findings include: Review of the medical record for Resident #30 revealed an admission date of 10/19/19. Diagnoses included multiple sclerosis, vascular dementia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic obstructive pulmonary disease, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident was dependent for toileting hygiene and personal hygiene. Review of a nurse's progress note dated 12/08/24 at 11:02 P.M. revealed the resident had an open area to the left ischium, barrier cream order in place and applied. The physician and resident representative were notified. The resident to be seen by wound care this week. Review of a nurse's progress note dated 12/08/24 at 11:05 P.M. revealed the resident had a stage two pressure ulcer to the left buttock measuring two centimeters (cm) in length by one cm in width, with a depth of 0.2 cm. There was no description of the wound bed. Review of the physician orders dated 01/28/24 revealed to apply barrier cream to buttocks and peri-area every shift and as needed after incontinent episodes. There were no new orders to apply the barrier cream to the newly identified area. Review of the treatment administration record (TAR) dated 12/08/24 through 12/12/24 revealed the barrier cream was applied to the buttocks and and peri-area every shift. This was no documentation the barrier cream was applied to the newly identified area. Review of a nurse practitioner (NP) wound care note dated 12/13/24 at 9:56 A.M. reveled the resident had a laceration to the left proximal posterior thigh. The wound was full thickness and measured three centimeters (cm) in length, 2.5 cm in width, with an undetermined depth. The wound was ten percent (%) granulation tissue and 90% slough with moderate serosanguinous drainage. The wound NP noted the resident was unable to tolerate debridement today. The wound was linear and may have been caused by the shower chair. The wound NP ordered to cleanse the wound with normal saline, apply silver (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 5 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 12/19/2024 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)