Health inspection·January 14, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of medical record, staff interview, and review of facility policy, the facility failed to ensure physician ordered medications were available for administration. This affected two residents (#26 and #80) of five (#26, #71, #80, #89, and #93) residents reviewed for accurate medical records. The Facility census was 92. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 11/02/23. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type II diabetes mellitus, vascular dementia, hyperlipidemia, hypertension (HTN), symptomatic epilepsy and epileptic syndrome, bipolar disorder, gastroesophageal reflux disease (GERD), and aphasia following cerebral infarction. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 11/22/24, revealed a Brief Interview of Mental Status (BIMS) score of 00, indicating Resident #26 was severely cognitively impaired. Review of the current physician orders for Resident #26 revealed an order dated 09/12/24 for Famotidine (a medication used to treat ulcers of the stomach and intestine and prevent ulcers from coming back after they have healed) oral suspension reconstituted 40 milligrams (mg) per 5 milliliters (ml). The order was to administer 5 ml via PEG (a percutaneous endoscopic gastrostomy (PEG) tube is a tube that is surgically placed into the stomach to allow a person to receive nutrition and medications when they are unable to swallow orally) tube at bedtime for acid reflux. Review of the medication administration record (MAR) for Resident #26 revealed the resident did not receive the ordered 5 ml dose of Famotidine on 12/15/24, 12/19/24, 12/21/24, 12/22/24, and 12/24/24. Review of the MAR for Resident #26 revealed the entry on 12/15/24 stated hold, see nurses note. Review of the nurse progress note dated 12/15/24 for Resident #26 revealed Famotidine 5 ml was on order. Review of the MAR for Resident #26 revealed the entry on 12/19/24 stated hold/see nurses note. Review of the nurse progress notes for Resident #26 dated 12/19/24 revealed Famotidine 5 ml was documented as not available. Review of the MAR for Resident #26 revealed the entry on 12/21/24 stated hold/see nurses note. (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 6 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 01/14/2025 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)