Health inspection·October 24, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, staff interview, and policy review, the facility failed to ensure medications were administered per physician orders. Additionally, the facility failed to maintain controlled substance drug records. This affected four (#118. #24, #117, #84) of seven residents reviewed for medication administration. The facility census was 99. Findings include 1. Review of the medical record for Resident #118 revealed an admission date of 03/30/23 and a discharge date of 06/26/24. Diagnoses included Alzheimer's disease with late onset, chronic obstructive pulmonary disease, dementia, chronic kidney disease, hypertension, and chronic diastolic heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the physician orders dated 06/18/24 revealed the resident was ordered Ceftriaxone sodium injection solution reconstituted one gram, inject one gram intramuscularly one time only for infection for one day. There was no type of infection documented for indication of use. Review of the medication administration record for 06/18/24 revealed the resident was administered the incorrect antibiotic. The resident was administered cefazolin sodium injection solution reconstituted one gram. Review of a medication incident report dated 06/18/24 at 12:45 P.M. revealed Registered Nurse (RN) #341 administered the antibiotic cefazolin instead of the antibiotic ceftriaxone. RN #341 had signed out the incorrect medication out of the contingency supply. The resident had no allergies to the medication and no adverse effects were observed. The five medication rights was reviewed with the nurse. Review of a nurse's note dated 06/18/24 at 4:20 P.M. revealed cefazolin one gram for injection given instead of ceftriaxone one gram for injection. The nurse practitioner was notified. Will continue to monitor the resident. Interview on 10/24/24 at 7:35 A.M., the Director of Nursing (DON) revealed the newer nurse had pulled the wrong medication and was educated. The DON revealed the physician was contacted. The DON verified there was no documentation for the indication of use for the medication and the nurse was educated to include the type of infection in the order. 2. Review of the medical record for Resident #24 revealed an admission date of 05/26/23. Diagnoses included type two diabetes mellitus, lymphedema, heart failure, atrial fibrillation, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Review of the physician orders dated 08/31/24 revealed an order for oxycodone-acetaminophen 10/325 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366022 If continuation sheet Page 2 of 4 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 10/24/2024 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 0755 milligrams (mg) by mouth every four hours as needed for pain. Level of Harm - Minimal harm or potential for actual harm Review of the controlled substance scheduled drug record revealed 17 doses of the oxycodone acetaminophen were pulled from the medication cards for one dose on 09/10/24, two doses on 09/11/24, one dose on 09/12/24, one dose on 09/21/24, two doses on 09/22/24, one dose on 09/24/24, two doses on 09/26/24, one dose on 09/28/24, one dose on 09/29/24, one dose on 09/30/24, two dose on 10/01/24, one dose on 10/02/24 and one dose on 10/09/24. Residents Affected - Some Review of the medication administration records from 09/01/24 through 10/09/24 revealed the 17 doses pulled from the medication card were not documented as administered on the medication administration record. Interview on 10/22/24 at 3:46 P.M. RN #399 revealed controlled substances should be signed out in the narcotic book when pulled and then documented on the medication administration record when administered. Interview on 10/22/24 at 3:53 P.M., Licensed Practical Nurse (LPN) #351 revealed controlled substances should be signed out in the narcotic book then signed out on the medication administration record. Interview on 10/23/24 at 11:40 A.M., the DON verified 17 doses of oxycodone/acetaminophen 10/325 mg were pulled from the medication card and were not documented as administered in the medication administration record. 3. Review of the medical record for Resident #84 revealed an admission date of 06/13/23. Diagnoses included type two diabetes mellitus, osteoarthritis, and chronic kidney disease. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Review of the physician orders dated 06/21/24 revealed orders for oxycodone oral capsule five milligrams (mg) by mouth every six hours as needed for a pain level of eight to ten on a zero to ten scale. Review of the controlled substance scheduled drug record revealed oxycodone was removed from the medication card for one dose each on 09/17/24, 09/19/24, 09/23/24, 09/28/24, 10/16/24 and two doses on 09/26/24. Review of the medication administration record revealed the medication pulled on 09/17/24, 09/19/24, 09/23/24, 09/28/24, 10/16/24 and 09/26/24 were not documented as administered on the medication administration record. Interview on 10/23/24 at 11:50 A.M., the DON verified seven doses of oxycodone were pulled from Resident #84's medication card and never documented as administered in the medication administration record. 4. Review of the medical record revealed Resident #117 had an admission date of 06/27/24 and a discharge date of 07/17/24. Diagnoses include down syndrome, hydrocephalus, Barrett's esophagus, and scoliosis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366022 If continuation sheet Page 3 of 4 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 10/24/2024 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 0755 Review of the five-day MDS assessment dated [DATE] revealed the resident had impaired cognition. Level of Harm - Minimal harm or potential for actual harm Review of the physician orders dated 07/12/24 revealed an order for morphine sulfate 20 mg/milliliter (ml), give 0.3 ml by mouth every one hour as needed for shortness of breath/pain. Residents Affected - Some Review of the medication administration record dated 07/01/24 through 07/17/24 revealed the resident was administered the morphine sulfate once on 07/13/24, three times on 07/14/24, three times on 07/15/24, six times on 07/16/24, and three times on 07/17/24. Review of the medical record revealed there was no controlled substance scheduled drug record for removal of the 16 doses of morphine sulfate. Interview on 10/23/24 at 1:49 P.M., the DON verified the facility was unable to locate the controlled substance record for morphine sulfate administered on 07/13/24 through 07/17/24 for Resident #117. Review of the policy, Medication Administration General Guidelines, revised 03/20/18, revealed medication were administered in accordance with written orders of the attending physician. Review of policy, Order Procedure and Accountability for Controlled Medications, last revised 11/30/18, revealed when a controlled medication dose was removed from control inventory, the licensed nurse immediately documents the date and time of removal for administration, amount to be removed for administration, signature of the nurse removing the medication dose on the proof-of-use sheet (Scheduled Drug Record Form). Administration of the dose is also documented on the medication administration record or the electronic medication record after the medication was administered. This deficiency represents non-compliance investigated under Complaint Number OH00158689 and Complaint Number OH00157665. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366022 If continuation sheet Page 4 of 4