Manor at Perrysburg failed to perform neurological assessments after five documented falls involving two residents between June and July, according to a federal inspection completed in August. The facility's own protocol required such evaluations after unwitnessed falls.
Resident 53 fell three times in five weeks. Resident 68 fell twice in three weeks. Neither received the brain injury screenings that facility leadership confirmed were required.
Regional Director of Clinical Services confirmed to inspectors that no neurological assessments were completed after Resident 53's falls on June 22, June 25, and July 30. The same administrator confirmed no assessments were done for Resident 68's falls on June 9 and July 31.
The Director of Nursing separately confirmed that post-fall assessments were skipped for both residents' most recent falls.
Resident 12, diagnosed with Alzheimer's disease and dementia, illustrated the facility's broader failure to follow its own fall prevention measures. The 83-year-old woman experienced two documented falls where staff failed to implement basic safety interventions they had promised after previous incidents.
On April 16 at 3:15 a.m., staff heard Resident 12 calling for help and found her sitting on the floor with her back against the bed, legs extended. She wasn't wearing non-slip footwear. The resident told staff she had slid off the bed.
Staff noted no injuries and created a new intervention: encourage staff to apply non-slip socks at all times when shoes weren't on.
Three months later, that intervention had been ignored.
On July 12 at 10:35 p.m., Resident 12 was discovered lying on her back on the bathroom floor with legs extended and knees slightly flexed. She didn't have her walker with her. She didn't have shoes on. No non-slip socks either.
Staff put non-slip socks on her feet after the fall and added a new intervention: place a reminder sign to use her walker.
A regional clinical nurse confirmed to inspectors that the resident wasn't wearing the non-slip socks when she fell in July, despite that being the specific safety measure implemented after her April fall. The nurse also confirmed there was no documentation showing whether the resident was compliant with keeping the socks on.
The facility's care plan for Resident 12, dated June 25, acknowledged she was at high risk for falls due to "potential adverse effects from prescribed medications and diagnosis of Alzheimer's/dementia negatively impacting safety awareness."
Planned interventions included encouraging non-slip footwear, encouraging walker use, keeping the bed in the lowest position, keeping the call light within reach, keeping frequently used items within reach, encouraging non-slip socks when shoes weren't on, and keeping the room free from clutter.
Yet when Resident 12 fell in the bathroom in July, she didn't have her walker and wasn't wearing the non-slip socks that were supposed to prevent exactly that type of incident.
The facility's "Head Injury Routine" policy, last revised in March 2001, provided no guidance about performing neurological assessments after unwitnessed falls. This gap left staff without clear direction despite the clinical director's acknowledgment that such assessments were protocol.
The facility's "Fall Reduction Policy," revised in April 2016, required follow-up documentation for each shift for a minimum of three days after any fall, or longer if needed.
Resident 12's diagnoses included Alzheimer's disease, dementia with mood disturbance, hallucinations, major depressive disorder, and hypertension. She was admitted to the facility on February 28.
The inspection was conducted in response to a complaint filed as number 2579614.
Federal inspectors found the violations represented minimal harm or potential for actual harm, affecting few residents. But the pattern revealed a facility that created safety protocols it didn't follow and implemented interventions it didn't track.
Staff heard Resident 12 calling for help after her first documented fall. Three months later, she was alone on a bathroom floor without the basic safety equipment her care team had promised to ensure she used.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Manor At Perrysburg from 2025-08-21 including all violations, facility responses, and corrective action plans.