Inspection·September 25, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure accurate and descriptive wound assessments, timely treatment orders for an identified wound, and ensure wound interventions were in place for a resident with pressure ulcers. This affected one (#24) of two residents reviewed for pressure ulcers. The facility census was 67. Findings include:Review of the medical record revealed Resident #24 was admitted on [DATE]. Diagnoses included end stage renal failure, aphasia following cerebral infarction, dysphagia, and adult failure to thrive. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was severely cognitively impaired. Review of the Nursing Admission/readmission Evaluation dated 09/11/25 at 6:39 P.M. revealed Resident #24 was readmitted from the hospital and returned to the facility with no new bruises or wounds. Preexisting wounds on resident's buttocks and left heel were noted. There was no description or measurement of the wound on 09/11/25. Review of the Skin Condition Evaluation dated 09/12/25 revealed on (re)admission, there was a suspected deep tissue injury (DTI) to the left heel measuring 1.4 centimeters (cm) in length by (x) 3.2 cm in width x 0.0 cm in depth. There was no wound treatment ordered on 09/11/25 or 09/12/25. The first wound treatment to the left heel was initiated on 09/17/25. The physician order dated 09/16/25 revealed an order for bilateral heel protectors on at all times when in bed. The physician order, dated 09/17/25, revealed an order for the left heel, cleanse with wound cleanser/normal saline and leave open to air twice a day. The wound assessment report dated 09/17/25 revealed the DTI pressure ulcer to the left heel measuring 1.3 cm x 3.5 cm x 0.0 cm. The care plan dated 09/18/25 revealed Resident #24 had impaired skin integrity to the left heel pressure ulcer with interventions including bi-lateral heel protectors on at all times when in bed. The wound assessment report dated 09/24/25 revealed a DTI pressure ulcer to Resident #24's left heel measuring 1.6 cm x 2.9 cm x 0.0 cm and noted to be improving without complications. Observation on 09/24/25 at 8:46 A.M. revealed Resident #24 was lying in bed on his back with his eyes closed and heels on the mattress. There were no heel protectors in place. Interview on 09/24/25 at 8:50 A.M. with Licensed Practical Nurse (LPN) #376 verified Resident #24 was in bed and did not have heel protectors on. LPN #376 located the heel protectors in the closet. Interview on 09/24/25 at 10:09 A.M. with the Director of Nursing (DON) verified the Nursing Admission/readmission Evaluation was completed inaccurately. The resident had a new heel wound (not existing) and verified there was no descriptions of the wounds to the left heel and buttocks. Interview on 09/25/25 at 11:34 A.M. with Registered Nurse (RN) #360 verified completing the skin assessment report including wound description with measurements on 09/12/25 and no physician treatment orders for the left heel were in not implemented until five days later on 09/17/25. Review of the policy titled Wound Management Policy dated 05/20/24 revealed upon admission upon admission, resident specific categorical skin risk factors are assessed, documented, care planned, and care plan interventions are operationalized, monitored, and evaluated. Residents with impaired skin Residents Affected - Few (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: 366188 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 366188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Toledo Snf 131 North Wheeling Street Toledo, OH 43605 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)