Health inspection·March 6, 2024

F 0686 amount of serosanguineous drainage. However, no staging was recorded or indicated. Level of Harm - Minimal harm or potential for actual harm On 02/27/24 a physician order was obtained for the sacrum wound to include: cleanse with normal saline (NS), apply silver alginate, cover with border foam. Change three times a week and as needed (PRN) on day shift every Tuesday, Thursday, Saturday. According to treatment administration records the treatment was provided on scheduled days last applied on 03/02/24 during the 7:00 A.M. to 7:00 P.M. shift. No documentation contained in the medical record indicated a PRN application had been applied after 03/02/24. Residents Affected - Few Further review of the medical record lacked documented wound measurements, monitoring or evaluation between 02/06/24 and 03/05/24. Review of nursing wound documentation on 03/05/24 at 2:57 P.M. recorded the sacrum wound as Stage III measuring .0.6 cm x 0.5 cm x NM with light serous drainage. The right heel wound was unstageable measuring 1.5 cm x 0.2 cm x 0.5 cm with light serous drainage. Observation on 03/05/24 at 11:18 A.M. with wound nurse Licensed Practical Nurse (LPN) #300 and State Tested Nurse Aide (STNA) #400 revealed Resident #3 was noted incontinent of a large amount of stool per adult brief. STNA #300 and LPN #300 removed the brief and positioned the resident on the left side exposing the sacral dressing. The dressing applied to the sacrum was heavily soiled with stool and was discovered under the dressing and in contact with the wound. Closer observation discovered the dressing applied to the sacrum included a abdominal dressing (ABD) with two pieces of tape securing the dressing to the resident. Interview with LPN #300 at the time confirmed the physician ordered dressing was not in place for Resident #3. LPN #300 proceeded to cleanse Resident #3's wound and obtain measurements of 6.0 cm x 5.5 cm with no depth assessed and described as a Stage 3 pressure ulcer. Interview with STNA #400 at the time stated the ABD dressing was applied when first checked at approximately 7:30 A.M. and 9:30 A.M. On 03/05/24 at 11:35 A.M. interview with LPN #302 revealed she assumed Resident #3 care at 7:00 A.M. LPN #302 stated she was not informed by the off going nurse Resident #3 sacrum dressing was not applied as ordered. On 03/06/24 at 8:35 A.M. interview with wound nurse LPN #300 during review of the medical record confirmed no accurate or weekly measurements obtained regarding Resident #3 sacral wound and heel wound since 01/30/24 when returned from the hospital. Wounds are to be measured and evaluated each Tuesday. Measurements with wound descriptions are to be obtained on admission and weekly according to policy. The medical record documented a nursing readmission assessment on 01/31/24. But did not record the sacrum wound description or depth, and right heel wound lacked measurements or wound description. No measurements or monitoring was recorded until 02/06/24. However, wound measurements were not accurately documented. The sacrum wound was documented to measure 0.8 x 0.6 x 1.5 cm and was to be recorded as 8.0 cm x 6.0 cm x 1.5 cm. Further review of the record lacked wound measurements or documentation until 03/05/24 with sacrum measurement inaccurately documented as 0.6 cm x 0.5 cm x NM (no measurement) stage III when the actual wound measurements were 6.0 cm x 5.5 cm x 0.1. Wound Nurse LPN #304 went on to state Resident #3 wounds were evaluated at the hospital on [DATE]. However, attempts to contact the hospital and obtain wound information was unsuccessful. Review of the facility Pressure Ulcer Policy revised 04/29/26 all residents will be assessed for pressure ulcer risk on admission, weekly and quarterly. A resident with a pressure ulcer will receive interventions and monitoring to promote healing, prevent infection, and prevent new ulcers from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366022 If continuation sheet Page 2 of 3 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 366022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor at Perrysburg 250 Manor Drive 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few developing. Should a pressure area present either upon admission or in house, the wound will be monitored at least weekly and should have documentation including: 1. Location and Staging. 2. Size (perpendicular measurements of the greatest extent of length and width of the ulceration), depth; and the presence, location and extent of any undermining or tunneling/sinus tract. 3. Drainage, the amount and characteristics. 4. Pain if present and characteristics. 5. Wound bed and surrounding tissue. This deficiency represents non-compliance investigated under Complaint Number OH00150960. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366022 If continuation sheet Page 3 of 3