Health inspection·April 1, 2024

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, and staff interview, the facility failed to ensure residents were provided with assistive devices as ordered/care planned. This affected one (Resident #27) out of three residents reviewed for assistance with drinking. The facility census was 104. Residents Affected - Few Findings include: Review of the medical record for Resident #27 revealed an admission date of 12/22/23 with diagnoses including but not limited to hemiplegia/hemiparesis following cerebral infarction affecting right dominant side, type two diabetes, cognitive communication deficit, vascular dementia, disorientation, delirium, essential tremor, and hypertension. Review of Resident #27's Medicare 5-day Minimum Data Set assessment, dated 12/28/23, revealed Resident #27 had a brief interview of mental status score of zero which indicated severe cognitive impairment. Resident #27 required supervision/touching to moderate assistance for activities of daily living. Resident #27 was dependent on staff for transfers. Review of the Nursing Interdisciplinary Meeting Note, dated 03/07/24, revealed nursing would write an order to provide Resident #27 with two handled cup with lid to increase the residents independence with drinking liquids. Review of Resident #27's Care Plan, dated 03/20/24, revealed Resident #27 had increased nutrition/hydration needs related to a recent stroke, vascular dementia, epilepsy, and significant weight change. Interventions included but were not limited to two handled cups with all meals and drinks. Review of Resident #27's physician order, dated 03/27/24, revealed Resident #27 was to have a two handled cup with lid for all drinks. Observation on 03/27/24 at 8:09 A.M. of Resident #27's room revealed there was a full cup of ice water with a lid, straw, and no handles located on the over the bed table across the room and out of reach of Resident #27. The breakfast tray was observed on the same table with drinks which were in smooth cups with lids and no handles. Observation on 03/27/24 at 10:57 A.M. of Resident #27's room revealed there was a full cup of ice water with a lid, straw, and no handles on the over the bed table across the room and out of reach of Resident #27. Observation on 03/27/24 at 1:00 P.M. of Resident #27's lunch tray revealed none of the residents (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 2 Event ID: 366022 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 04/01/2024 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)