Manor At Perrysburg

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

progress notes confirmed there was no indication in Resident #13's chart to explain why the wound treatment was not completed on 12/23/25. The DON further stated Resident #13's wound treatments should have been completed on 12/23/25, as ordered by the physician.Follow-up interview on 12/24/25 at 2:28 P.M. with the DON revealed she spoke with LPN #202, who charted on Resident #13's chart on 12/23/25. The DON stated LPN #202 confirmed she did not complete Resident #13's wound treatments because she ran out of time on her shift.This was an incidental finding identified during the complaint survey completed 12/24/25.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/24/2025

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)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, review of meal tickets, staff and resident interviews, and review of Resident Council meeting minutes, the facility failed to ensure residents received menu items as selected at mealtime. This affected two (#11 and #15) of four residents reviewed for accuracy of meal tray food items. The facility census was 106.Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 01/09/24 with diagnoses including hemiplegia, type II diabetes mellitus, and overactive bladder. Review of

the annual comprehensive Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #11 had intact cognition and was able to eat independently.Interview on 12/24/25 at 8:48 A.M. with Resident #11 revealed she generally did not receive the choices she selected on her menus for lunch and dinner.Observation during meal service on 12/24/25 at 12:55 P.M. with Licensed Practical Nurse (LPN) #203, and concurrent interview, confirmed Resident #11 did not receive the vegetable soup she selected on her meal ticket. Further interview with LPN #203 revealed residents complained about not receiving items

they select on their meal tickets.Interview on 12/24/25 at 12:59 P.M. with Certified Nursing Assistant (CNA) #101 revealed she was able to provide Resident #11's vegetable soup upon request from the surveyor.2.

Review of the medical record for Resident #15 revealed an admission date of 10/22/25 with diagnoses including hypertensive heart disease, type II diabetes mellitus, and heart failure.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #15 had intact cognition and required setup or clean-up assistance for eating.Observation during meal service on 12/24/25 at 12:05 P.M. revealed Certified Nursing Assistant (CNA) #102 providing Resident #15 her noon meal. Concurrent

interview and review of the selective menu for Resident #15 revealed she selected crackers and did not receive them on her tray. CNA #102 was able to provide the crackers from an unused meal tray for a resident who was out of the facility.Interview on 12/24/25 at 12:59 P.M. with CNA #101 confirmed CNAs were responsible for passing out menu tickets for lunch and dinner meals the day before service, and ensuring the meal tickets were completed by residents and returned to the kitchen by 6:00 P.M. Additionally, CNA #101 confirmed residents complained about not receiving the items they requested. CNA #101 further stated she was able to coordinate with her co-workers and the kitchen to obtain the requested items timely

during meal service. Review of the Resident Council Food Committee notes, dated 11/03/25, revealed a concern regarding menus not being filled out and residents not getting what they request.This deficiency represents non-compliance investigated under Complaint Number 2664244.

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