Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Manor At Perrysburg during CMS and state inspections, most recent first.
A resident with chronic wounds did not receive daily wound care as ordered by the physician. Although wound treatments were documented as completed on the TAR, interviews and observation revealed that the dressings had not been changed for two days, and staff confirmed the treatments were either not done or documented before completion. The DON verified there was no explanation in the chart for the missed treatments.
Two residents with intact cognition and multiple medical conditions did not receive the food items they selected on their meal tickets, such as vegetable soup and crackers. Staff interviews and Resident Council notes confirmed ongoing complaints about residents not receiving their requested menu items, despite CNAs being responsible for collecting and submitting meal selections to the kitchen.
Staff did not serve residents seated together at the same table at the same time during meals, instead passing trays randomly from the cart and leaving some residents waiting while others ate. A resident with Alzheimer’s disease and dementia also remained with long visible chin hairs after a shower, despite needing assistance with personal hygiene and stating she wanted them removed because they were embarrassing.
The facility did not complete required post-fall and neurological assessments for two residents after unwitnessed falls, as confirmed by staff interviews and record review. Additionally, fall prevention interventions, such as ensuring non-skid socks and walker use, were not consistently implemented or documented for a resident at risk for falls. Facility policies lacked clear guidance on neurological assessments after unwitnessed falls, contributing to these deficiencies.
Psychotropic medication education was not completed before a resident started Divalproex Sodium, Sertraline HCl, and Trazodone HCl. The resident had diagnoses including bipolar disorder, depression, insomnia, stroke, and dementia, and the MDS showed the resident was rarely or never understood. The DON confirmed the facility could not provide evidence that the resident or her representative received education and alternatives before the medications were given.
Incomplete Comprehensive Care Plans: The facility failed to ensure comprehensive care plans included all resident care areas for two residents. One resident had a documented foot wound and physician wound orders, but the care plan only addressed skin breakdown risk and did not include the actual skin impairment or interventions. Another resident with PTSD had no care plan for the diagnosis, triggers, or interventions, despite severe cognitive impairment and the facility policy requiring a comprehensive person-centered care plan with measurable objectives and timetables.
Failure to clean and trim a resident's fingernails. A resident with Alzheimer's disease, COPD, and depression was dependent on staff for personal hygiene, and the care plan called for staff participation with personal hygiene. During observation, the resident stated his fingernails needed trimming, and debris was seen under the nails on both hands. A CNA later confirmed the resident had been showered and dressed on the night shift, but the nails were still long with debris under them.
Incomplete wound assessment and documentation: A resident with dementia had a right foot wound that was not consistently measured or described in facility records. CNA shower checks and weekly skin reviews noted no new skin issues, while hospice and wound physician notes showed changing wound descriptions and measurements, including two separate right foot wounds. Facility staff could not locate complete wound documentation for multiple periods, despite policy requiring weekly documentation of wound location, size, depth, drainage, pain, and surrounding tissue.
Failure to implement ordered heel offloading interventions. A resident with ESRD, CHF, CKD, lymphedema, impaired mobility, and existing pressure ulcers had physician-ordered pressure off-loading boots and heel floating in place, but repeated observations found both heels resting on the mattress without the boots in use. The resident stated the boots were not applied overnight, a CNA confirmed they were not offered or applied, and an RN verified they were not used despite being documented as applied in the MAR.
A resident with Parkinson's disease, DM2, psychosis, and adult failure to thrive, who was under hospice care and dependent for all ADLs, had an order for Magic Cup twice daily with meals. Staff confirmed the supplement was ordered and in stock, but during meal observation the noon tray did not include the supplement even though the meal ticket showed it should have been served.
Incorrect Tracheostomy Equipment at Bedside: A resident with a tracheostomy had bedside respiratory supplies that did not match the physician order. During observation, an LPN found a size #7 cuffless trach outer cannula and could not confirm it was appropriate for the ordered #4 cuffless trach; the LPN later confirmed it was too large and located the correct size 6.5 mm outer cannula among other supplies in the room.
Missing Dialysis Assessments: A resident with ESRD, dementia, and psychiatric diagnoses received dialysis on a M/W/F schedule, but the EMR contained no pre- or post-dialysis assessments. The RCN stated staff were not completing post-dialysis assessments and were only sending a pre-assessment with the resident to the dialysis center for completion, but the facility could not produce the required assessments.
A resident with severe cognitive impairment and multiple neuropsychiatric diagnoses received Lovenox for DVT prophylaxis after hospital discharge, but the order remained unclear across follow-up notes and no documentation showed staff sought clarification of the stop date for an extended period. The neurology CNP stated the office did not manage Lovenox and that the resident would not need it once Plavix was restarted, while the DON confirmed the record lacked evidence of timely clarification.
The facility failed to complete timely nutrition assessments for a resident with Parkinson's disease, DM2, psychosis, and adult failure to thrive. The record showed the resident became a significant change, was rarely/never understood, was dependent for all ADLs, and was admitted to hospice, but only an older quarterly nutrition note was found and no comprehensive nutrition assessment was completed after the hospice admission. The DTR confirmed the assessment should have been completed.
EBP was not followed during tracheostomy care for a resident with a tracheostomy, respiratory failure, and a hx of MRSA. Although EBP signage was posted and PPE was available in the room, an RN provided tracheostomy care without donning a gown during a high-contact care activity, and the RN confirmed the lapse.
A resident with multiple chronic conditions was discharged home with a three-day supply of medications, but the facility did not send prescriptions to the external pharmacy until eight days later, causing a delay in medication access. Additionally, the facility failed to notify Social Security of the discharge within a timely manner, with notification occurring 13 days after discharge due to internal communication and equipment issues.
A resident with a PEG tube was affected by a medication administration error when an LPN failed to follow updated physician orders and facility policy. The resident, who had begun eating and taking fluids orally, was supposed to receive medications crushed in applesauce or pudding. Instead, the LPN attempted to administer the medications through the PEG tube without adding water, causing it to clog. The DON confirmed the error and the need for reviewing orders before administration.
An LPN at the facility failed to adhere to proper medication administration protocols, affecting three residents. A resident with a PEG tube received medications incorrectly, leading to a clogged tube. Another resident was exposed to potential medication errors due to the LPN preparing medications for multiple residents simultaneously. Additionally, a resident with diabetes received insulin injections improperly, with discrepancies in blood glucose documentation.
A facility failed to maintain a medication error rate below 5%, with an LPN making 11 errors affecting three residents. Errors included improper administration through a PEG tube, failure to start a nebulizer treatment, and incorrect insulin administration. The LPN did not adhere to physician orders or facility policies, leading to a 19% error rate.
A resident with diabetes type two received insulin injections that were not administered according to the manufacturer's guidelines. An LPN failed to hold the insulin pen in place for the required 10 seconds, administering the injection too quickly. Additionally, there was a discrepancy in the documented blood glucose level, with the LPN recording a different value than what was observed. The DON confirmed these actions were not in compliance with facility policies.
The facility failed to provide physician-ordered medications to two residents, resulting in a deficiency. One resident with severe cognitive impairment and GERD did not receive Famotidine on multiple occasions due to unavailability. Another resident with moderate cognitive impairment and GERD missed doses of Omeprazole, with records indicating the medication was out of stock or unavailable. The DON confirmed these issues, noting a lack of documentation for marking the medication as not required.
A facility failed to ensure residents were free from significant medication errors, affecting three residents. A resident with severe cognitive impairment missed multiple doses of Novolog insulin, while another missed a dose of Lantus insulin. A third resident with intact cognition did not receive a morning dose of Insulin Glargine. These incidents were confirmed by the DON and indicate non-compliance with the facility's medication administration policy.
A facility failed to ensure proper infection control when an RN did not wear gloves while administering insulin to a resident with type II diabetes. The facility's policy requires gloves for tasks involving potential exposure to blood or body fluids. The RN confirmed the oversight during an interview.
The facility failed to administer medications per physician orders and maintain controlled substance records, affecting four residents. Errors included administering the wrong antibiotic to a resident and failing to document the administration of oxycodone and morphine for others. These issues highlight lapses in medication management and documentation procedures.
A facility failed to complete a comprehensive care plan for a resident with impaired cognition and incontinence. Despite the resident's diagnoses and continuous incontinence, the care plan lacked an incontinence care section. Interviews confirmed the oversight, and the facility's policy mandates completion within seven days post-assessment.
The facility failed to provide a resident with the prescribed two-handled cup for drinking, despite the resident's severe cognitive impairment and need for assistance. Observations showed drinks were in smooth cups without handles and placed out of reach. Interviews confirmed the deficiency, revealing a lack of communication between nursing staff and the kitchen.
Failure to Complete Physician-Ordered Wound Treatments
Penalty
Summary
A deficiency occurred when wound treatments for a resident with multiple chronic wounds, including non-pressure ulcers on the right foot and calf, were not completed as ordered by the physician. The resident's medical record showed daily wound care orders, including cleansing with normal saline, application of calcium alginate with silver, and appropriate dressings. Documentation on the Treatment Administration Record (TAR) indicated that treatments were recorded as completed on consecutive days, but interviews and direct observation revealed that the treatments had not actually been performed. Specifically, the wound dressings had not been changed since two days prior, as evidenced by the date and staff initials on the gauze, and the resident reported not receiving wound care since the beginning of the week. Further investigation through staff interviews confirmed that one LPN documented completion of wound care before actually performing it, and another LPN admitted to not completing the treatment due to running out of time during the shift. There was no documentation in the resident's chart explaining the missed treatments, and the Director of Nursing confirmed that the wound care should have been completed as ordered. The deficiency was identified during a complaint survey and was substantiated by resident interview, staff interview, record review, and direct observation.
Failure to Provide Residents with Selected Menu Items
Penalty
Summary
The facility failed to ensure that residents received the menu items they selected at mealtime, as evidenced by observations, interviews, and review of records. Two residents with intact cognition and specific medical diagnoses, including hemiplegia, type II diabetes mellitus, hypertensive heart disease, and heart failure, did not receive the food items they had chosen on their meal tickets. One resident did not receive vegetable soup as selected, and another did not receive crackers, despite both items being available and provided only after staff intervention during the meal service. Staff interviews confirmed that residents frequently complained about not receiving their requested menu items. Further review revealed that CNAs were responsible for distributing and collecting menu tickets, but there were ongoing issues with ensuring residents' selections were honored. Resident Council Food Committee notes documented concerns about menus not being filled out and residents not getting what they requested. These findings demonstrate a pattern of the facility not providing food according to residents' documented preferences and selections.
Residents Not Served Together at Meals; Facial Hair Not Removed
Penalty
Summary
The facility failed to ensure that residents in the memory care unit were served together during meals. During breakfast observations, trays were delivered to the dining room on an open cart and staff removed plates and drinks and placed them in front of residents without serving by table. Residents seated at the same table were served at different times, with some residents eating while others at the same table waited several minutes for their meals. One resident stated he wanted to eat at the same time as his friend and said he had been in the dining room since 6:30 A.M. A CNA confirmed that the tables were not served together and that trays were passed out as they came off the cart rather than in sequence by table. This pattern was observed on multiple mornings. On one morning, 16 residents were in the dining room and staff passed trays without serving by table; at a seven-person table, residents were still waiting while others at the same table had already been served, and the last resident at that table was not served until 9:20 A.M. On another morning, 17 residents were in the dining room and the same issue occurred, with residents at the large table waiting while others were served first. During lunch, the first meal cart was delivered with meals already arranged, and the dietary supervisor stated the trays were then split so that the seven-top table received meals from the first cart while the remaining meals were delivered on the second cart. The facility also failed to ensure a female resident was free from long facial hair. The resident had diagnoses of Alzheimer's disease and dementia, with intact cognition on the quarterly MDS and a care plan indicating she required setup and assistance with personal hygiene. She received a shower in the early morning, but later that morning she was observed sitting in her room with several long chin hairs that she could pull at with her fingers. She stated she did not have the eyesight to remove them herself and wanted them removed, but had not asked staff. Later that day, after another shower, the chin hairs were still present and visible, and the resident again said she found them embarrassing. A CNA confirmed the chin hairs should have been removed during the shower.
Failure to Complete Post-Fall and Neurological Assessments and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that post-fall assessments, including neurological assessments, were completed for residents who experienced unwitnessed falls. Specifically, two residents with histories of falls did not receive neurological assessments after their unwitnessed falls, despite facility protocol requiring such assessments. Additionally, post-fall assessments were not completed for certain incidents. Interviews with the Regional Director of Clinical Services and the Director of Nursing confirmed that these assessments were not performed as required. Review of facility policies revealed a lack of clear guidance regarding neurological assessments after unwitnessed falls, and documentation did not support that follow-up was conducted as outlined in the fall reduction policy. The facility also failed to implement and document fall prevention interventions for a resident at risk for falls. This resident, with diagnoses including Alzheimer's disease and dementia, experienced multiple falls where prescribed interventions such as non-skid socks and use of a walker were not in place at the time of the incidents. Documentation did not confirm whether the resident was compliant with these interventions, and new interventions were added after each fall without evidence of consistent implementation. These failures were identified through observation, staff interviews, record review, and policy review.
Psychotropic Medication Education Not Completed Before Initiation
Penalty
Summary
The facility failed to ensure the psychotropic education form was completed before starting psychotropic medications for one resident. Resident #30 was admitted with diagnoses of insomnia, bipolar disorder, depression, stroke, and dementia, and the 5-day MDS assessment indicated the resident was rarely or never understood. The resident had physician orders for Divalproex Sodium 250 mg twice daily for bipolar disorder, Sertraline HCl 50 mg once daily for depression, an additional Sertraline HCl 100 mg once daily for depression, and Trazodone HCl 50 mg once daily for insomnia. During interview, the DON confirmed the facility could not provide evidence that the resident or her representative received education and alternatives to these psychotropic medications before the resident received them.
Incomplete Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure the comprehensive care plan included all resident care areas for Resident #77 and Resident #98. Resident #77 was admitted with diagnoses including Alzheimer's disease, dementia, and visual hallucinations, and the MDS showed severely impaired cognition. The resident had a right lateral foot wound with physician orders for cleansing and dressing changes, but the care plan only addressed risk for skin breakdown related to decreased mobility and did not include a care plan for the actual skin impairment or related interventions. During interview, the RCN stated the resident did not have an actual skin impairment care plan until that day and said the facility had been waiting for the wound physician to classify the wound before implementing a care plan. Resident #98 was admitted with diagnoses including Alzheimer's disease, generalized anxiety disorder, dementia, and PTSD, and the quarterly MDS showed severe cognitive impairment and PTSD. The care plan dated 06/23/25 did not include a care plan for PTSD, including triggers or interventions. The MDS Coordinator stated the MDS Nurse typically completes resident care plans and that the facility was training other nurse managers to complete certain parts of the care plans, and verified that Resident #98 did not have a care plan addressing PTSD and related triggers or interventions. The facility policy stated that each resident should have a comprehensive person-centered care plan with measurable objectives and timetables to meet identified medical, nursing, mental, and psychosocial needs.
Failure to Clean and Trim Resident Fingernails
Penalty
Summary
The facility failed to ensure a resident's fingernails were cleaned and groomed. Resident #68, admitted on 09/20/19 with diagnoses of Alzheimer's disease, chronic obstructive pulmonary disease, and depression, was assessed on the annual MDS as having intact cognition and being dependent on staff for personal hygiene. The care plan, updated 07/10/25, stated the resident required staff participation with personal hygiene. During observation on 08/18/25, the resident was lying in bed and stated his fingernails needed to be trimmed; debris was observed under the fingernails on both hands. On 08/19/25, a CNA stated the resident had been showered and dressed during the night shift, and concurrent observation showed the resident's nails were long with debris under the nails of the first two fingers of each hand. The CNA confirmed nails should be cleaned and trimmed during showers.
Incomplete Wound Assessment and Documentation
Penalty
Summary
The facility failed to timely ensure a resident's right foot wound was accurately assessed and documented. The resident had an admission diagnosis history including Alzheimer's disease, dementia, and visual hallucinations, and the MDS reflected severe cognitive impairment with no pressure ulcers coded. Physician orders later directed wound care to the right lateral foot, but facility skin monitoring forms and weekly skin reviews repeatedly documented no new skin issues or no new areas noted, despite the presence of a wound. Record review showed inconsistent and incomplete wound documentation over time. Hospice notes described the area first as a dry flat red area, then later as a pressure injury with changing measurements, and one hospice note documented no wound assessment even though the pressure ulcer was present. A wound physician later identified two non-pressure wounds on the right foot, including one with dried fibrinous exudate and another full-thickness wound with erythema, heavy serosanguinous drainage, and granulation tissue. Observation of the resident's right lateral foot showed two open areas, but the facility could not locate wound documentation with measurements and descriptions for multiple date ranges, and the facility's policy required weekly monitoring with documentation of location, staging, size, depth, drainage, pain, and wound bed and surrounding tissue.
Failure to Implement Ordered Heel Offloading Interventions
Penalty
Summary
The facility failed to ensure that interventions ordered to prevent skin breakdown were implemented for a resident with end stage renal disease, chronic kidney disease, congestive heart failure, lymphedema, impaired range of motion to both lower extremities, dependence on staff for activities of daily living, and a history of pressure ulcers. The resident had a stage II pressure ulcer to the right heel and a stage IV pressure ulcer to the right buttock, along with two non-pressure wounds. A physician order had been implemented for heel offloading/suspension boots at all times, and the wound physician specialist later documented continued use of pressure off-loading boots, floating heels in bed, and skin prep to the right heel each shift after the heel wound was noted healed. Facility observations on multiple occasions showed the resident in bed with both heels resting on the mattress surface and without the pressure off-loading boots in use. During one observation, the resident stated the boots were not applied during the night and nursing staff did not offer them. A CNA confirmed the boots were not offered or applied during the night, and an RN verified the boots had not been applied during the night and were nevertheless documented as applied in the medical record. The record contained no documentation that the resident refused the heel offloading boots or heel elevation, and the treatment administration record documented the boots as applied during both shifts.
Nutrition Supplement Not Provided as Ordered
Penalty
Summary
The facility failed to ensure a nutrition supplement was provided as ordered for Resident #50, who was admitted with Parkinson's disease, type II diabetes mellitus, unspecified psychosis, and adult failure to thrive and was under hospice care. The resident's significant change MDS assessment indicated she was rarely or never understood and was dependent for all activities of daily life. A physician order dated 01/17/25 directed that she receive Magic Cup twice daily with meals to supplement calorie intake. During interview, the DTR confirmed the resident was to receive Magic Cup twice daily, and the Dietary Manager confirmed the supplement was in stock and that the resident was supposed to receive it on lunch and dinner trays. However, during observation of the noon meal tray, no nutrition supplement was present, and the CNA and meal ticket review confirmed the resident should have received a Magic Cup on that tray.
Incorrect Tracheostomy Equipment at Bedside
Penalty
Summary
Proper respiratory care was not provided for a resident with a tracheostomy when the facility failed to ensure the correct emergency tracheostomy equipment was available at the bedside. Resident #7 was admitted with respiratory failure and tracheostomy status, had intact cognition on the quarterly MDS, and had a care plan directing staff to keep an extra tracheostomy tube and obturator at bedside. The resident also had physician orders for tracheostomy maintenance and for tracheostomy type/size monitoring. During observation of the resident’s room, staff found a resealable bag containing a single size 5.5 inner cannula tracheostomy tube and a single size #7 cuffless tracheostomy outer cannula. The LPN could not determine whether the size #7 cuffless tracheostomy outer cannula matched the physician order for a #4 cuffless tracheostomy tube and found no other outer tracheostomy tubes among the supplies on the resident’s counter. The LPN later confirmed the size #7 cuffless trach was too large for the resident and was not appropriate, and then located the correct size 6.5 mm outer cannula in a box under other supplies in the resident’s room.
Missing Dialysis Assessments
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident who required dialysis. Resident #54 was admitted on 07/05/25 with diagnoses including Alzheimer's disease, major depressive disorder, generalized anxiety disorder, schizoaffective disorder depressive type, end stage renal disease, and vascular dementia. The MDS dated [DATE] indicated the resident was cognitively intact, and current physician orders showed dialysis scheduled for Monday, Wednesday, and Friday. Review of the electronic medical record found no dialysis assessments. During interview, the Regional Clinical Nurse stated the facility did not complete post-dialysis assessments when residents returned from dialysis and that, although pre- and post-dialysis assessment forms existed in the electronic system, staff were not completing them. The RCN also stated the facility was doing a pre-assessment and sending it with the resident to the dialysis center for completion, but the facility could not produce pre- and post-dialysis assessments. The facility policy titled Dialysis Care Policy dated 02/2018 stated the manor will provide ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility.
Unnecessary Lovenox Use Due to Unclear Stop Date
Penalty
Summary
Ensure each resident's drug regimen was free from unnecessary drugs was not met for one resident with severe cognitive impairment and multiple diagnoses including Alzheimer's disease, epilepsy, major depressive disorder with psychotic features, dementia with psychotic disturbance, delusional disorders, generalized anxiety disorder, schizoaffective disorder, and a history of subdural hematoma. The resident was admitted with orders for Lovenox for blood clot prevention after hospital discharge, and the record showed conflicting and unclear directions across subsequent notes regarding whether Lovenox should continue, including references to continuing it until activity returned to baseline and until neurosurgery follow-up, while later neurology notes continued Lovenox without addressing a stop date. The facility record showed no documentation from 06/11/25 through 08/20/25 that staff asked for clarification of the Lovenox order. A health status note documented that staff attempted to contact the neurology CNP office on 08/20/25, but no return call had been received at that time. During interview, the neurology CNP stated the office did not manage Lovenox and that the resident's attending physician or cardiologist should monitor it, and also stated the resident would not need Lovenox once Plavix had been restarted. The DON confirmed the discharge and follow-up notes did not clearly address the Lovenox plan and that there was no documentation showing staff contacted the physician or CNP for clarification of the stop date. Medscape information reviewed by surveyors stated that Lovenox for DVT prophylaxis in medical patients with restricted mobility is typically given for 6 to 11 days, with up to 14 days used in clinical trials.
Delayed Nutrition Assessment After Hospice Admission
Penalty
Summary
The facility failed to ensure nutrition assessments were completed timely for one resident (#50) reviewed for nutrition. Resident #50 was admitted on 09/27/24 with diagnoses including Parkinson's disease, type II diabetes mellitus, unspecified psychosis, and adult failure to thrive. The record showed a significant change comprehensive MDS assessment dated 07/21/25 indicating the resident was rarely/never understood and was dependent for all activities of daily life. A physician order dated 07/15/25 showed the resident was admitted to hospice, but the medical record contained only a quarterly nutrition progress note completed on 04/29/25 and no more recent quarterly or annual nutrition assessment. No comprehensive nutrition assessment was completed after the resident's significant change and hospice admission. During interview on 08/21/25, the DTR confirmed a comprehensive nutrition assessment should have been completed when the resident was admitted to hospice and confirmed none had been completed since that admission.
EBP Not Followed During Tracheostomy Care
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were practiced during tracheostomy care for one resident with a tracheostomy. Resident #7 was admitted with respiratory failure, tracheostomy status, and a history of MRSA infection. Her medical record showed she was care planned for EBP because of her tracheostomy and gastric feeding tube, and current physician orders for August 2025 did not include an order for EBP. The facility identified only one resident with a tracheostomy, and the census was 96. On observation, Resident #7 had an EBP sign posted above her bed and PPE was available in her room. During observed tracheostomy care, RN #490 did not don a gown while providing care. During interview, RN #490 verified that Resident #7 was on EBP and confirmed she did not wear a gown during the high-contact resident care activity, despite PPE being available in the room. The posted EBP signage stated that everyone must wear a gown and gloves for high-contact resident care activities including tracheostomy care.
Failure to Provide Timely Discharge Medications and Notification to Social Security
Penalty
Summary
The facility failed to ensure a resident received timely access to prescribed medications upon discharge and did not provide timely notification to Social Security (SS) regarding the resident's discharge. The resident, who had multiple diagnoses including frontotemporal neurocognitive disorder, diabetes, hypertension, and multiple myeloma, was discharged to his home with a three-day supply of medication. However, the prescriptions for ongoing medications were not sent to the external pharmacy until eight days after discharge, resulting in a delay in the resident receiving his medications. Staff interviews confirmed that the discharge prescriptions were not sent as intended, and there was no confirmation of the prescriptions being faxed on the day of discharge. Additionally, the facility did not notify SS of the resident's discharge in a timely manner. The Business Office Manager (BOM) acknowledged that notification to SS was delayed by 13 days due to issues with the fax machine and lack of access to alternative faxing methods. The BOM also stated that there was no written policy regarding the timeframe for SS notification at the time of the incident, and that previous guidance allowed for up to 30 days, which was later changed to three days by the corporate office. The deficiency was identified through review of the electronic medical record, external pharmacy records, staff and family interviews, and facility policy. The resident involved was cognitively intact at the time of discharge, and interviews with the resident and his son indicated that no physical or psychosocial harm resulted from the delay in medication. The facility's discharge summary policy required reconciliation of all pre- and post-discharge medications, but this process was not completed in a timely manner for this resident.
Medication Administration Error via PEG Tube
Penalty
Summary
The facility failed to ensure medications were administered via feeding tube per physician orders for Resident #15, who was admitted with diagnoses including sick sinus syndrome, traumatic brain injury, dysphagia, and dementia. The resident's care plans indicated the use of a PEG tube for nutrition and medication administration due to dysphagia. However, on 03/25/25, the physician orders were updated to allow medications to be crushed in applesauce or pudding and taken orally, as the resident had begun eating and taking fluids by mouth. Despite this change, an LPN prepared and attempted to administer the resident's medications through the PEG tube without adding water to the crushed pills, causing the tube to clog. The LPN was unaware of the updated orders and did not follow the facility's policy for medication administration via feeding tube, which requires medications to be crushed finely and mixed with water to prevent clogging. The Director of Nursing confirmed the oversight and noted the need for reviewing physician orders prior to medication administration.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure that nursing care was provided in accordance with standards and practices, affecting three residents during medication administration. Resident #15, who had a PEG tube for feeding due to dysphagia, was observed receiving medications incorrectly. The LPN prepared and attempted to administer crushed medications through the PEG tube without adding water, causing the tube to clog. The LPN did not review the updated physician orders, which had changed the route of medication administration to oral, and was unaware of the resident's fluid restrictions. Resident #16, who had intact cognition and was on multiple medications, was affected by the LPN's practice of preparing medications for multiple residents simultaneously. The LPN was observed entering Resident #16's room with medications for another resident, which is against facility policy. This practice increases the risk of medication errors and demonstrates a lack of adherence to proper medication administration protocols. Resident #18, who had diabetes and was receiving insulin injections, was also impacted by the LPN's improper practices. The LPN administered insulin using a Flex-pen without holding the needle in the skin for the recommended 10 seconds, as per the manufacturer's guidelines. Additionally, there was a discrepancy in the recorded blood glucose level, which was documented incorrectly in the resident's MAR. These actions indicate a failure to follow established procedures for insulin administration and accurate documentation.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 19% affecting three residents. During a medication administration observation, an LPN was noted to have made 11 medication errors while administering medications to three residents. The errors included improper administration techniques and failure to adhere to physician orders. For Resident #15, the LPN attempted to administer medications through a PEG tube despite the resident's orders having been changed to oral administration. The LPN did not add water to crushed medications before attempting to administer them through the PEG tube, resulting in the tube becoming clogged. The LPN was unaware of the resident's fluid restrictions and did not review the updated physician orders prior to administration. Resident #17 did not receive a nebulizer treatment as ordered because the LPN failed to turn on the nebulizer machine and did not verify the start of the treatment. For Resident #18, the LPN prepared medications for multiple residents simultaneously, entered a room with another resident's medications, and administered insulin too quickly, not adhering to the facility's policy of holding the insulin pen for 10 seconds. Additionally, the LPN documented an incorrect blood glucose reading in the resident's MAR.
Improper Insulin Administration and Documentation Discrepancy
Penalty
Summary
The facility staff failed to properly administer insulin medications according to the manufacturer's guidelines, affecting one resident. The resident, who has diabetes type two, was observed receiving insulin injections that were not administered correctly. The LPN responsible for administering the insulin did not follow the facility's policy of holding the insulin pen in place for a full 10 seconds after injection, as required by the manufacturer's guidelines. Instead, the LPN administered the injection quickly and removed the pen immediately, which was not in line with the facility's practice. Additionally, there was a discrepancy in the documentation of the resident's blood glucose levels. The LPN documented a blood glucose level of 216 in the Medication Administration Record (MAR), whereas the actual observed level was 228. This inconsistency in documentation further highlights the deficiency in the administration of medication. The Director of Nursing confirmed that the LPN's actions were not in compliance with the facility's policies, and the LPN was responsible for administering medications to all residents in the facility.
Medication Availability Deficiency for Two Residents
Penalty
Summary
The facility failed to ensure that physician-ordered medications were available and administered to two residents, leading to a deficiency. Resident #26, who was severely cognitively impaired and had multiple diagnoses including GERD, did not receive the prescribed Famotidine on several occasions due to the medication being unavailable. The medication administration record (MAR) and nurse progress notes indicated that the medication was on order or not available on the specified dates, which was confirmed by the Director of Nursing (DON). Similarly, Resident #80, with moderate cognitive impairment and a diagnosis of GERD, did not receive the prescribed Omeprazole on multiple dates. The MAR and nurse progress notes documented that the medication was unavailable or out of stock, and there was no documentation to support the medication being marked as not required on one occasion. The DON confirmed the non-administration of the medication and noted the absence of any hold parameters in the physician's order that would justify the medication being marked as not required.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting three out of five residents reviewed. Resident #26, who was severely cognitively impaired, did not receive the ordered sliding scale dose of Novolog insulin on three separate occasions. This was confirmed by the Director of Nursing (DON) during an interview. Resident #26 had multiple diagnoses, including diabetes mellitus, hemiplegia, and vascular dementia, which required careful management of their medication regimen. Resident #89, also severely cognitively impaired, did not receive the scheduled afternoon dose of Lantus insulin on one occasion. Similarly, Resident #93, who had intact cognition, missed a morning dose of Insulin Glargine. The facility's policy on medication administration, which mandates that medications be administered as prescribed, was not adhered to in these instances. These deficiencies were identified during a complaint investigation, highlighting non-compliance with the facility's medication administration guidelines.
Failure to Wear Gloves During Insulin Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during medication administration. Specifically, a Registered Nurse (RN) did not wear gloves while administering 16 units of Lantus SoloStar Solution Pen-injector to a resident with type II diabetes mellitus. This incident was observed during a medication administration session. The facility's policy, revised on 08/09/16, mandates that all personnel must wear gloves when performing tasks that involve potential exposure to blood or body fluids, including when working with sharp items. The RN confirmed during an interview that gloves were not worn during the administration of the insulin injection.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders and did not maintain proper controlled substance drug records, affecting four residents. For Resident #118, a medication error occurred when a registered nurse administered cefazolin instead of the prescribed ceftriaxone. The error was documented, and the resident experienced no adverse effects. However, there was no documentation for the indication of use for the medication. For Resident #24, there was a discrepancy in the controlled substance records, with 17 doses of oxycodone-acetaminophen being pulled from the medication card but not documented as administered in the medication administration record. Similarly, for Resident #84, seven doses of oxycodone were removed from the medication card without documentation of administration. These discrepancies indicate a failure to properly document the administration of controlled substances. Resident #117's records revealed that 16 doses of morphine sulfate were administered without a corresponding controlled substance record. The facility was unable to locate the documentation for these doses. The facility's policies require that controlled medications be documented immediately upon removal and administration, but these procedures were not followed, leading to the deficiencies noted in the report.
Incomplete Comprehensive Care Plan for Incontinence
Penalty
Summary
The facility failed to ensure a comprehensive care plan was timely completed for a resident with multiple diagnoses, including chronic obstructive pulmonary disease, chronic kidney disease, vascular dementia, and atrial fibrillation. The resident, who was admitted on an unspecified date, was found to have impaired cognition and was always incontinent of bowel and bladder according to the admission Minimum Data Set (MDS) assessment. Despite these findings, the comprehensive care plan dated October 1, 2024, and last revised on October 12, 2024, did not include a care plan for incontinence care. Interviews with facility staff revealed that the resident was unaware of their incontinence, and the MDS Coordinator confirmed that the comprehensive care plan was incomplete. The facility's policy, last revised in November 2016, requires that a comprehensive care plan be developed within seven days after the completion of the comprehensive assessment. However, this requirement was not met, as verified by the MDS Coordinator, who acknowledged the omission of the incontinence care plan for the resident.
Failure to Provide Assistive Drinking Devices
Penalty
Summary
The facility failed to ensure that Resident #27 was provided with assistive devices as ordered and care planned. Resident #27, who had severe cognitive impairment and required assistance for activities of daily living, was supposed to use a two-handled cup with a lid for all drinks. Despite this, multiple observations revealed that the resident's drinks were provided in smooth cups with lids and no handles, and the cups were often placed out of the resident's reach. This was confirmed through observations on several dates, where the resident's drinks were consistently not in the prescribed two-handled cups and were placed on an over-the-bed table that was not accessible to the resident due to fall prevention measures in place in the room. Interviews with the Director of Nursing (DON) and the Food Service Supervisor (FSS) confirmed the deficiency. The DON acknowledged that the resident's drinks were not in the appropriate cups and were not within reach, explaining that staff would offer the resident a drink when they entered the room. The FSS revealed that the kitchen had not been informed to provide the two-handled cup for the resident's meals, as nursing staff had not filled out the necessary dietary slip. This deficiency was investigated under Master Complaint Number OH00152085.
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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) |
|---|---|---|---|---|
| Three Meadows Post Acute | 0.8 mi | ★★★★★ | 13 | 1 |
| Avalon By Otterbein At Perrysburg | 0.8 mi | ★★★★★ | 23 | 0 |
| Kingston Health Center Of Perrysburg | 1 mi | ★★★★★ | 0 | 0 |
| Concord Care Center Of Toledo | 3.4 mi | ★★★★★ | 31 | 0 |
| Majestic Care Of Perrysburg | 3.6 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.