Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kingston Health Center Of Perrysburg during CMS and state inspections, most recent first.
Improper labeling and storage of food items were observed in multiple kitchen and resident dining area refrigerators and freezers. Expired salad dressings were found in the kitchen, and several resident food items lacked required labels, room numbers, expiration dates, or opened-on dates. An LPN verified the missing information and discarded the items; facility policy required food items to be properly labeled and date marked.
Residents receiving OT/PT were not informed of daily therapy schedules. A cognitively intact resident with multiple chronic conditions and a surgical wound said therapy arrived at unscheduled times, disrupting showers, wound care, family visits, and personal plans, and sometimes leaving meals cold. Other residents in a council meeting reported the same issue, and the DOT confirmed therapy did not set resident schedules unless requested.
A resident with atrial fibrillation, CHF, chronic PE, DM2, and a left ischium fracture had an order for apixaban 5 mg BID, but the care plan only addressed cardiovascular distress and did not include monitoring for bleeding risk related to anticoagulant use. The DON confirmed the resident lacked a care plan for excessive bleeding risk, and the facility policy required care plan interventions to reflect resident-specific risk areas or disease processes.
Delayed Response to Resident Call Light: A resident with multiple chronic conditions and full assistance needs had her call light alarm for 35 to 39 minutes while requesting toileting assistance. An LPN verified the prolonged alarm, and the resident stated staff were slow to answer her call light and that this upset her. An LPN and CNA later entered the room to assist her to the restroom; the Administrator stated call lights should ideally be answered within 5 to 10 minutes and never remain unanswered for more than 30 minutes.
A resident receiving IV meds had a VAD dressing that was not changed per the MD order or facility policy. The resident, who had a joint infection and intact cognition, reported the dressing had not been changed since admission. Observation showed the dressing still dated from the original placement, the MAR showed it was due earlier, and an SDRN confirmed it was past due.
A resident with cerebral infarction, aphasia, hemiplegia/hemiparesis, and severe cognitive impairment was ordered to wear a right resting hand orthotic at HS, but repeated observations found the splint not applied and the hand in a closed fist position. CNAs reported the splint was often not on, the resident often refused it, and no alternative interventions or refusals were documented; the DON confirmed this.
Fall Interventions Not in Place for a Resident at Risk for Falls: A resident with multiple fractures, generalized weakness, moderately impaired cognition, and a history of falls had a care plan calling for a low bed and bilateral floor mats. Surveyors observed only one mat in place, with the other mat across the room, and a CNA confirmed the mat was not positioned as indicated. The resident’s family also stated both mats were not being used.
The facility failed to timely address one resident’s significant, unplanned weight loss and did not ensure another resident’s request for a protein snack after HD was honored. One resident with multiple chronic conditions, including dysphagia and CKD, lost 8.88% of body weight over about one month before any documented intervention was initiated. Another resident with ESRD, CHF, and fracture-related diagnoses reported not eating on HD days and asked for a post-HD protein snack, but staff could not verify that the planned snack was ever ordered or provided.
Significant delay in Carbidopa-Levodopa administration: A resident with Parkinson's disease, dementia, dysphagia, and total functional dependence had an order for Carbidopa-Levodopa twice daily, but the morning dose was not given until several hours after the scheduled time. An LPN confirmed the dose was late and stated facility policy required meds to be administered within 60 minutes of the ordered time; the manufacturer also states the medication should be taken at regular intervals per the prescriber’s directions.
Unsecured medication was found in a resident’s room when a white oblong pill was observed on the bedside table and later retrieved from the resident’s shirt by an RN. The resident had dementia, a BIMS score of 3, required assistance for all functional abilities, and did not have an order to self-administer meds. Staff identified the pill as a potassium chloride tablet that had been administered earlier that day by an LPN.
Failure to Place a Resident on EBP: A resident with ESRD and a hemodialysis port to the left chest was not placed on EBP as required by facility policy. The resident had intact cognition, needed assistance with toileting hygiene and showering, and had orders to monitor the dialysis port for signs and symptoms of infection, but no EBP order was present. The DON verified the resident should have been in EBP and was not currently on EBP.
A facility failed to ensure staff wore appropriate PPE for a COVID-19 positive resident, with an occupational therapist observed without a gown, eye protection, or gloves. Additionally, the facility did not complete required weekly water flushes to prevent Legionella pneumophila, with maintenance logs showing incomplete records and no evidence of flushing from June to August 2024.
The facility failed to provide adequate window coverings in the dining rooms, leading to discomfort for residents due to bright sunlight. Observations showed only sheer curtains were present, insufficient to block the glare. Residents expressed concerns about the brightness, but staff were unaware of these complaints. The facility's policy on comfortable lighting was not followed.
A resident, who is six feet, six inches tall, was provided with a bed that was too short, causing discomfort and difficulty sleeping. Despite a tall bed being ordered upon admission, observations showed the resident's head at the top of the mattress and legs bent with pillows. Staff interviews revealed awareness of the issue, but the facility's policy on accommodating residents' needs was not effectively implemented.
The facility failed to conduct quarterly care conferences for two residents, as required by policy. One resident, with cognitive impairment and multiple diagnoses, had no documented care conference since November 2023. The LSW confirmed the resident's representative declined meetings over the summer, and the interdisciplinary team did not document their meetings as care conferences. Another resident, cognitively intact with severe medical conditions, had no care conference documented since April 2024, and the resident could not recall attending one. The facility's policy requires care update meetings every 90 days.
The facility failed to assist two male residents with shaving due to a lack of proper equipment and staff availability. One resident, with hemiplegia and diabetes, had an uneven beard and was unable to shave due to his condition. Another resident, with hemiplegia and dysphasia, also could not receive assistance for shaving. The facility's policy on shaving was not effectively implemented, leading to this deficiency.
A facility failed to implement ordered pressure ulcer interventions for a resident with multiple pressure ulcers. Despite physician orders to off-load heels and use a pressure-relieving air cushion, observations showed the resident's heels were not elevated, and the cushion was turned off. The facility's policy emphasized these interventions, but they were not consistently applied.
A resident with quadriplegia was found to have unsafe gaps between their mattress and bed rails, with measurements of 5.25 inches on the left and 3.25 inches on the right. The DON confirmed these gaps were too large and potentially unsafe, and the facility could not provide manufacturer guidelines for acceptable distances.
A resident with quadriplegia and communication difficulties was unable to use the standard call light system due to his condition. His electronic communication board, which was not connected to the call light system, was placed out of his visual range, preventing him from requesting assistance. Staff interviews confirmed the resident's inability to use the call light and the improper placement of his communication board.
The facility did not complete reference checks for new hires, including STNAs, an RN, an Environmental Services Manager, an Activity Director, and a Maintenance Manager. The HR Manager indicated that the corporate office advised that reference checks were no longer legally required, resulting in the omission.
Improper Labeling and Storage of Food Items
Penalty
Summary
Food was not stored in a sanitary manner in the facility kitchen and resident dining area refrigerators and freezers. In the first-floor kitchen refrigerator, surveyors observed a container of salad dressing with an expiration date of 04/26/26 and a container of Italian salad dressing with an expiration date of 06/28/26. An LPN verified both expired containers and removed them from the refrigerator and discarded them. In the third-floor patient dining area, surveyors observed an unmarked Styrofoam cup in the freezer containing a frozen substance, and a plastic bag marked with a room number but no expiration date that was leaking a sticky liquid. The bag contained a closed bag of chips, an unwrapped muffin, a plastic container of green leafy vegetables, a container that appeared to have salad dressing, and a container of grapes. In the second-floor dining area, a container with a name but no room number or expiration date contained an unknown food substance. In the first-floor Bistro area, surveyors found a plastic bag of food items with no name or date, another bag dated 05/05/26 containing French onion dip, and an opened jar of cherries without an opened-on date. The LPN verified the missing labels and dates and discarded the items. Facility policy required food and beverage items to be properly labeled, date marked, stored, and discarded in accordance with the facility's labeling and dating policy.
Residents Not Informed of Daily Therapy Schedules
Penalty
Summary
Residents were not fully informed of their daily therapy schedules. Resident #85, who was admitted with diagnoses including left above-knee amputation, Type II DM, hypertensive chronic kidney disease, malignant neoplasm of colon, alcoholic cirrhosis of the liver, anemia, and atrial fibrillation, was assessed as cognitively intact, dependent for ADLs, and at risk for pressure ulcers with a surgical wound. During observation and interview, Resident #85 stated he was unaware when OT or PT were scheduled each day and wanted to plan around showers, wound dressing changes, guest visits, and personal interests. He reported that therapy staff arrived at various unscheduled times, which interrupted visits and other planned activities, and that he sometimes returned from therapy to cold meals that needed reheating. During a Resident Council meeting, three residents who were receiving therapy services stated they were unaware when therapy would take them and described the process as inconvenient and non-informative. They reported therapy staff arrived in rooms while residents were visiting or conducting personal business, and that meals were sometimes cold when they returned from therapy. The Director of Therapy confirmed the therapy department did not set a schedule for resident therapy sessions unless the resident made a request. The Administrator later provided a list showing 54 current residents receiving therapy services.
Missing Care Plan for Anticoagulant Monitoring
Penalty
Summary
The facility failed to develop a care plan to address administration and monitoring of an anticoagulant medication for one resident out of 21 residents reviewed. Resident #20 was admitted with diagnoses including fracture of the left ischium, Type II diabetes mellitus, chronic pulmonary embolism, congestive heart failure, and atrial fibrillation. The MDS dated 06/12/26 showed a BIMS score of 15, indicating intact cognition, and no behaviors were documented. Functional abilities included dependence on others for sit-to-stand, chair-to-bed transfer, toilet transfers, and car transfers. Orders included Apixaban 5 mg by mouth twice daily for atrial fibrillation. The revised care plan dated 06/08/26 addressed potential cardiovascular distress related to peripheral vascular disease and atrial fibrillation, but it did not include a care plan for the risk of excessive bleeding related to anticoagulant medication. The DON confirmed on 07/15/26 that the resident did not have a care plan to monitor for the risk of excessive bleeding related to anticoagulants. The facility policy stated that care plan interventions should reflect risk areas or disease processes that impact the individual resident.
Delayed Response to Resident Call Light
Penalty
Summary
The facility failed to ensure Resident #112's call light was timely answered. Resident #112 was admitted with diagnoses including right achilles tendinitis, syncope and collapse, type 2 diabetes mellitus, hyperlipidemia, hypertension, morbid obesity, generalized anxiety disorder, orthostatic hypotension, hypothyroidism, neuralgia and neuritis, cervical disc degeneration, history of falling, generalized muscle weakness, difficulty walking, depression, and insomnia. Her most recent MDS assessment showed a BIMS score of 15, indicating she was cognitively intact, and that she required assistance for all functional abilities. On 07/14/26 at 7:31 A.M., the call light monitor showed Resident #112's call light had been alarming for 35 minutes. An LPN verified at that time that the call light had been alarming for 35 minutes. During interview, Resident #112 tearfully stated she had been pushing her call light for more than one-half hour to request help with toileting and said staff are slow to answer her call light, which she found upsetting. At 7:37 A.M., another LPN verified the call light had been alarming for 39 minutes, and at 7:38 A.M. an LPN and CNA entered the room to assist her to the restroom. The Administrator stated the facility did not have a specific policy for call light response time, but expected call lights to be answered timely and ideally within five to 10 minutes, with no call light unanswered for greater than 30 minutes.
VAD Dressing Change Not Completed per Order
Penalty
Summary
The facility failed to change a vascular access device (VAD) dressing according to the physician’s order and the facility policy for one resident receiving intravenous medications. Resident #38 was admitted with diagnoses including orthopedic surgery and infection/inflammatory reaction due to a right hip prosthesis. The resident’s admission MDS showed a BIMS score of 15, indicating intact cognition, and the care plan identified the need for IV medications related to a joint infection requiring antibiotics. A physician order dated 07/04/26 directed that the VAD dressing be changed every seven days. On 07/14/26, the resident stated the VAD dressing had not been changed since admission. Observation of the VAD on the resident’s upper right arm showed a dressing dated 07/04/26, and review of the MAR showed the dressing was due to be changed on 07/11/26. The Staff Development RN confirmed the order for dressing changes every seven days and verified that the dressing was still dated 07/04/26 and was past due to be changed. Facility policy stated VAD dressing changes are to be completed at routine intervals every five to seven days and as needed if the dressing integrity is disrupted.
Failure to Implement Ordered ROM Orthotic
Penalty
Summary
The facility failed to ensure interventions to promote range of motion were implemented as prescribed by the physician for Resident #56. The resident was admitted with diagnoses including cerebral infarction, aphasia, hemiplegia and hemiparesis affecting the right dominant side, hypertensive chronic kidney disease, Type II diabetes mellitus, anxiety disorder, and polyneuropathy. The most current MDS assessment noted severe cognitive impairment, no resistive behaviors, range of motion impairment on one side in both upper and lower extremities, dependence on staff for activities of daily living, bowel and bladder incontinence, and use of multiple medications including a diuretic, antiplatelet, hypoglycemic, and anticonvulsant. A physician order dated 05/28/26 directed application of a right resting whole hand finger orthotic at bedtime, and the care guide also listed the right finger orthotic for HS along with other positioning interventions. However, observations on 07/14/26, 07/15/26, and 07/16/26 showed the resident in bed without the resting hand splint in place, with the hand in a closed fist position. CNAs stated the splint was not on when care was assumed, one CNA said the resident often refused to wear it, and another CNA confirmed no alternative interventions had been attempted. The DON verified the resident often refused the splint and that no additional interventions or refusals were documented in the medical record.
Fall Interventions Not in Place for a Resident at Risk for Falls
Penalty
Summary
The facility failed to ensure that care-planned fall interventions were in place for Resident #108. The resident was admitted with multiple diagnoses including fractures of the lumbar spine, cervical spine, pubis, and scapula, along with asthma, chronic kidney disease, coronary artery disease, polyneuropathy, depression, dysphagia, generalized muscle weakness, and a history of falling. The resident’s most recent MDS assessment showed a BIMS score of 10, indicating moderately impaired cognition, and the assessment also showed the resident required assistance with all functional abilities. The care plan identified the resident as at risk for falls related to weakness and a history of falls with fractures, with interventions including staff assistance with transfers as needed, a low bed, and bilateral floor mats. During interview, the resident’s daughter and son-in-law stated the facility did not use both fall mats that were in the resident’s room. Observation showed the resident in bed with the bed in low position and one fall mat in place on the left side, but no mat on the right side; the missing mat was found across the room leaning against the wall. A CNA verified the mat was not in place as indicated and stated the resident was last observed earlier that morning. The facility policy stated that fall risk factors should be mitigated and preventative measures implemented, and that care plan interventions should be implemented.
Failure to Address Significant Weight Loss and Post-HD Nutrition Needs
Penalty
Summary
The facility failed to timely address a resident’s significant, unplanned weight loss. Resident #48 was admitted with multiple diagnoses including dysphagia, chronic kidney disease, anemia, and muscle weakness, and was cognitively intact but required assistance with all functional abilities. His weight was documented as 169 lbs on admission and again on 06/02/26, then 154 lbs on 07/08/26, reflecting an 8.88% loss over about one month. The record showed no documentation of communication or intervention for the weight loss until 07/14/26, when a dietetic technician noted the significant loss and discussed adding a nutritional supplement with the NP. A physician order for Ensure Clear was entered on 07/15/26, and the Administrator confirmed there were no interventions in place between discovery of the weight loss and that order. The facility also failed to ensure a resident’s request for a protein snack after hemodialysis was honored. Resident #42 was admitted with diagnoses including orthopedic fractures, end stage renal disease, kidney transplant, and congestive heart failure, and had intact cognition. The admission care plan identified increased caloric, protein, and nutrient needs and noted the resident was malnourished or at risk for malnutrition related to inadequate intake and metabolic demands. Physician orders included a consistent carbohydrate diet, 1800 mL fluid restriction, and a bedtime high protein-caloric snack. The resident stated she did not eat breakfast or lunch on hemodialysis days because she felt unwell during dialysis and reported asking the RD for a protein snack after returning from dialysis. The nutrition review documented that she was hungry after dialysis and planned for hard-boiled egg and sandwich in the afternoons and yogurt at lunch. However, the Unit Supervisor RN stated there was no order or diet change for the afternoon snack and could not verify that the resident was receiving or being offered the hard-boiled egg and sandwich after hemodialysis.
Significant delay in Carbidopa-Levodopa administration
Penalty
Summary
A significant medication error occurred for Resident #65, who was admitted with multiple diagnoses including Parkinson's disease, dementia, dysphagia, generalized weakness, and several other chronic and acute conditions. The resident's most recent MDS assessment showed a BIMS score of 3, indicating cognitive impairment, and the resident required assistance for all functional abilities. A physician order dated 07/06/26 directed Carbidopa-Levodopa 25-100 mg to be given twice daily at 7:00 A.M. and 3:00 P.M. On 07/15/26 at 10:33 A.M., observation showed the resident's ordered 7:00 A.M. dose of Carbidopa-Levodopa had not been administered until that time. During interview, the LPN confirmed the medication was ordered for 7:00 A.M. and was not given until 10:33 A.M. The LPN also stated the facility policy required medications to be administered within 60 minutes of the ordered time. The manufacturer's instructions for Carbidopa-Levodopa stated it is important that the medication be taken at regular intervals according to the prescribing physician's directions.
Unsecured Medication Found in Resident Room
Penalty
Summary
The facility failed to ensure medications were appropriately and safely stored. During observation, a white oblong pill was found on Resident #65’s bedside table, and when the resident picked it up, the pill dropped down her shirt. RN #271 later retrieved the pill from the resident’s shirt and confirmed it had been unsecured in the resident’s room. LPN #293 stated the resident did not have an order to self-administer medication. Resident #65 had an admission date of 06/29/26 and diagnoses including right femur fracture, generalized muscle weakness, oropharyngeal dysphagia, dementia, Parkinson’s disease, hypertension, Type Two Diabetes Mellitus, and other chronic conditions. Her most recent MDS, dated 07/02/26, showed a BIMS score of 3 and indicated she required assistance for all functional abilities. LPN #293 and RN #317 identified the pill as a 20 mEq potassium chloride tablet, and LPN #293 confirmed she had administered the ordered potassium chloride at 8:00 A.M. that same day. The facility policy stated medications are to be administered as prescribed and residents may self-administer only when specifically authorized by the attending physician.
Failure to Place Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure Resident #42 was placed in Enhanced Barrier Precautions (EBP) according to facility policy. Resident #42 was admitted with diagnoses including orthopedic surgery post fracture of the left tibia, fracture of the left fibula, end stage renal disease, kidney transplant, and congestive heart failure. The incomplete admission MDS showed a BIMS score of 15, indicating intact cognition, and no behaviors were documented. The IDT functional abilities assessment showed the resident needed substantial assistance with toileting hygiene, partial assistance with showering, and setup/cleanup assistance with personal hygiene. The admission care plan noted renal failure resulting in the need for hemodialysis, and physician orders included monitoring the dialysis port located to the left chest for signs and symptoms of infection once daily. Review of the orders showed no order for EBP. During interview, the DON verified that Resident #42 should have been in EBP because of the hemodialysis port to the left chest and also verified that the resident was not currently in EBP. The facility policy stated that EBP is to be in place during high-contact care activities for residents with indwelling medical devices, including central lines.
Inadequate PPE Use and Water Management in LTC Facility
Penalty
Summary
The facility failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) when providing care for a resident infected with COVID-19. The resident, who had intact cognition, was placed in droplet precautions in single room isolation. Despite the facility's policy requiring full PPE, including an N95 mask, gloves, eye protection, and a gown, an occupational therapist was observed not wearing a gown, eye protection, or gloves while in the resident's room. This was confirmed during an interview with the occupational therapist, who admitted to not wearing the required PPE while setting his things down in the resident's room. Additionally, the facility failed to complete weekly water flushes of equipment at risk for developing Legionella pneumophila, which could potentially affect all 55 residents. The maintenance logs indicated that the required weekly flushing of fixtures was only performed during the first week of each month from January to May 2024, with no logs available for June through August 2024. The Maintenance Manager, who had recently started working at the facility, confirmed the lack of evidence for weekly flushing as required by the facility's Water Management Protocol.
Inadequate Window Coverings in Dining Rooms
Penalty
Summary
The facility failed to provide adequate window coverings in the dining rooms to prevent glare, affecting three residents and potentially impacting eleven others who dined on the second floor. Observations revealed that the dining rooms on both the second and third floors had only sheer curtains, which were insufficient to block the bright sunlight coming through the windows. This issue was highlighted by Resident #108, who expressed discomfort due to the brightness and preferred to sit with her back to the windows. Similar concerns were echoed by Resident #41, who described the sunlight during dinner as blinding and uncomfortable. Interviews with staff, including the Director of Nursing and a Licensed Practical Nurse, indicated they were unaware of any resident complaints regarding the brightness. However, a State tested Nurse Aide reported that residents had voiced concerns, and a concern form was supposedly submitted to Human Resources. The Human Resources Manager, however, stated that she did not receive any such forms, and the Administrator did not recall receiving any complaints about the dining room's brightness. The facility's policy on providing a homelike environment, which includes comfortable lighting and glare reduction, was not adhered to, as confirmed by the observations and resident feedback.
Inadequate Bed Length for Tall Resident
Penalty
Summary
The facility failed to provide a bed long enough to accommodate the height of Resident #107, who is six feet, six inches tall. Upon admission, a tall bed was ordered for the resident, but observations and interviews revealed that the bed was still too short, causing discomfort. The resident was observed with his head at the top of the mattress and his legs bent at the knees with pillows, indicating the bed's inadequacy. The resident expressed discomfort and difficulty sleeping due to the bed's length. Interviews with staff, including the Assistant Director of Nursing (ADON) and a State Tested Nurse Aide (STNA), revealed awareness of the bed's inadequacy. The STNA had reported the issue to a nurse, but the ADON was not initially aware of the problem. Upon further investigation, the ADON discovered the bed was 80 inches long and ordered a longer bed. The facility's policy on accommodating residents' needs was not effectively implemented, as the resident's height was not adequately considered when ordering the bed.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure care conferences were offered quarterly for two residents, as required by their policy. Resident #13, who was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, hypertensive heart disease, major depressive disorder, and mixed hyperlipidemia, had not been assessed for cognition in the most recent MDS assessment. The last documented care conference for this resident was held on 11/02/23, and no further conferences were documented. The Licensed Social Worker (LSW) confirmed that the resident's representative did not want to meet over the summer, and although the interdisciplinary team met, they did not attempt to include the resident or document the meeting as a care conference. Similarly, Resident #41, admitted with diagnoses such as incomplete lesion at cervical spinal cord levels, acute and chronic respiratory failure, type two diabetes mellitus, and stage four pressure ulcers, was found to be cognitively intact in the MDS assessment. The last care conference documented for this resident was on 04/10/24, and no subsequent conferences were recorded. The resident could not recall having a care conference, and the LSW verified the absence of documentation for any care conference since April 2024. The facility's policy mandates care update meetings every 90 days, and the medical record should reflect if a meeting is canceled or not attended by the resident or representative.
Failure to Assist Residents with Shaving
Penalty
Summary
The facility failed to assist two male residents with shaving, despite their dependence on staff for this activity of daily living. Resident #22, who was admitted with diagnoses including hemiplegia, hemiparesis, and diabetes mellitus, required substantial assistance for personal grooming due to weakness and the inability to lift his left arm. Observations revealed that he had an uneven beard approximately 1.5 inches long, which he wanted shaved off. However, staff were unable to assist him due to a lack of proper equipment. Although the resident expressed his desire to have his beard shaved, staff informed him that they did not have time and suggested he wait until he returned home where he had the necessary equipment. Similarly, Resident #157, who was admitted with conditions such as hemiplegia, hemiparesis, dysphasia, and congestive heart failure, required setup assistance for personal hygiene, including shaving. Observations showed that he had about 1/2 inch of beard growth and was unable to receive assistance from staff. Interviews with nursing aides revealed that while residents typically brought their electric razors upon admission, the facility only provided disposable razors, which were ineffective for longer beards. The facility's policy on shaving emphasized promoting cleanliness and skin care, yet the lack of appropriate equipment and staff availability led to the deficiency in care for these residents.
Failure to Implement Pressure Ulcer Interventions
Penalty
Summary
The facility failed to implement pressure ulcer reducing interventions as ordered for a resident with multiple pressure ulcers. The resident, who was cognitively intact and required substantial assistance with daily activities, had a history of pressure ulcers, including a stage four ulcer on the sacral region and other sites. Physician orders included off-loading heels when in bed and using a pressure-relieving air cushion in the wheelchair. However, observations revealed that the resident was not wearing heel boots, and their heels were not elevated while in bed, contrary to the care plan. Further observations showed that the alternating pressure wheelchair seat cushion was turned off, which was confirmed by an LPN who stated it needed to be plugged in and turned on. The facility's policy on pressure injury assessment and prevention emphasized the importance of offloading heels and using devices for repositioning to prevent pressure injuries. Despite these guidelines, the facility did not ensure the interventions were consistently implemented, as evidenced by the resident's statements and staff verification.
Unsafe Bed Rail and Mattress Configuration
Penalty
Summary
The facility failed to ensure the safety of bed rails and mattresses for a resident with quadriplegia and acute and chronic respiratory failure. The resident, who was dependent on staff for all Activities of Daily Living (ADLs) and rarely/never understood, was observed lying on an air mattress with significant gaps between the mattress and bed rails. These gaps were measured at 5.25 inches on the left side and 3.25 inches on the right side, which were confirmed by the Director of Nursing (DON) to be potentially unsafe. The deficiency was identified during an observation and confirmed through interviews with staff, including a Licensed Practical Nurse (LPN) and the DON. The facility was unable to provide manufacturer guidelines for the acceptable distance between the mattress and bed rails, but the DON acknowledged that the existing gaps were too large and posed a safety risk. This issue affected one of the two residents reviewed for bed rails, highlighting a lapse in ensuring the safety and appropriateness of bed rail and mattress configurations.
Failure to Provide Accessible Call Light System for Resident with Quadriplegia
Penalty
Summary
The facility failed to ensure that a resident with quadriplegia and communication difficulties had access to a functional call light system. Resident #32, who was dependent on staff for all Activities of Daily Living (ADLs) and had been working with speech language pathology therapy to use an eye gaze device, was observed with a standard push-call light button clipped to his bed, which he could not use due to his condition. The resident's electronic communication board, which he used to communicate, was not connected to the call light system, and staff frequently checked on him instead. Further observations revealed that the electronic communication board was placed out of the resident's visual range, rendering it unusable for him to request assistance. Staff interviews confirmed that the resident was unable to use the standard call light and that the communication board was not within reach. Despite the facility's policy requiring staff to ensure residents can use the call system, the resident's needs were not adequately met, as evidenced by the lack of a suitable call light system for his condition.
Failure to Complete Reference Checks for New Hires
Penalty
Summary
The facility failed to complete reference checks for new hires, which could potentially affect all residents. Personnel file reviews revealed that several staff members, including State tested Nursing Aides, a Registered Nurse, an Environmental Services Manager, an Activity Director, and a Maintenance Manager, were hired without completed reference checks. The Human Resource Manager stated that the corporate office had informed the facility that reference checks were no longer required by law, leading to the omission of these checks.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Perrysburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manor At Perrysburg | 1 mi | ★★★★★ | 2 | 0 |
| Three Meadows Post Acute | 1.7 mi | ★★★★★ | 13 | 1 |
| Avalon By Otterbein At Perrysburg | 1.7 mi | ★★★★★ | 0 | 0 |
| Concord Care Center Of Toledo | 2.7 mi | ★★★★★ | 5 | 0 |
| Heatherdowns Rehab & Residential Care Center | 3 mi | ★★★★★ | 13 | 0 |
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