Health inspection·May 15, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Based on review of facility electronic medical record (EMR), review of external provider documents, staff interview, interview with external provider staff, and policy review, the facility failed to ensure a resident timely received medications upon discharge. Additionally, the facility failed to ensure timely notification of Social Security (SS) of discharge. This affected one (#110) of three residents (#110, #112, and #114) reviewed for discharge rights. Findings include: 1. Review of the EMR for Resident #110 revealed an admission date of 07/25/24 and a discharge date of 03/12/25 with diagnoses including frontotemporal neurocognitive disorder, type two diabetes mellitus (DM2), Vitamin D deficiency, hyperlipidemia, frontal lobe and executive dysfunction, retention of urine, dementia in other diseases classified elsewhere, gastroesophageal reflux disease (GERD), constipation, atrial fibrillation (a. fib), hereditary and idiopathic neuropathy, hypertension (HTN), and multiple myeloma not having received remission. Review of the most recent State Minimum Data Set (MDS) Assessment for Resident #110, dated 03/11/25, revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #110 was relatively cognitively intact. Review of the EMR for Resident #110 revealed a discharge date of 03/12/25 to his personal home. a. Review of the Interdisciplinary Discharge Summary and Plan of Care (DC POC) revealed Resident #110 was discharged on 03/12/25 with a three-day supply of medication and prescriptions (Rx) were called to the external pharmacy by RSC #320 on 03/13/25. Prescriptions included with the DC POC included Eliquis Oral Tablet 5 mg (milligram), give 1 tablet by mouth two times a day for anticoagulant, a-fib related to essential hypertension; Cardizem CD Capsule Extended Release 24 Hour 120 mg , give 1 capsule by mouth one time a day for a-fib; Ropinirole Hydrochloride 1 mg, give 1 tablet by mouth one time a day for restless legs at HS (bedtime); Atorvastatin Calcium Tablet 10 mg (Atorvastatin Calcium), give 1 tablet by mouth one time a day for cholesterol related to hyperlipidemia; Lisinopril Oral Tablet 5 mg, give 1 tablet by mouth one time a day for heart related to hypertension; Isosorbide Mononitrate ER Tablet Extended Release 24 hour 30 mg, give 1 tablet by mouth one time a day for hypertension related to essential hypertension; Acyclovir Oral Tablet (Acyclovir), give 400 mg by mouth one time a day for prevention of herpes zoster secondary to above diagnosis related to multiple myeloma; Dutasteride Oral Capsule 0.5 mg, give 1 capsule by mouth one time a day related to urinary retention; Flomax Capsule 0.4 mg, give 1 capsule by mouth one time a day related urinary retention; Lyrica Oral Capsule 75 mg, give 1 capsule by mouth three times a day for neuropathy related to neuropathy; Cholecalciferol Tablet 1000 unit, give 1 tablet by mouth one time a day for Vitamin D3 deficiency; (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 3 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 05/15/2025 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)