Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Manor At Perrysburg during CMS and state inspections, most recent first.
A resident with chronic wounds did not receive daily wound care as ordered by the physician. Although wound treatments were documented as completed on the TAR, interviews and observation revealed that the dressings had not been changed for two days, and staff confirmed the treatments were either not done or documented before completion. The DON verified there was no explanation in the chart for the missed treatments.
Two residents with intact cognition and multiple medical conditions did not receive the food items they selected on their meal tickets, such as vegetable soup and crackers. Staff interviews and Resident Council notes confirmed ongoing complaints about residents not receiving their requested menu items, despite CNAs being responsible for collecting and submitting meal selections to the kitchen.
The facility did not complete required post-fall and neurological assessments for two residents after unwitnessed falls, as confirmed by staff interviews and record review. Additionally, fall prevention interventions, such as ensuring non-skid socks and walker use, were not consistently implemented or documented for a resident at risk for falls. Facility policies lacked clear guidance on neurological assessments after unwitnessed falls, contributing to these deficiencies.
A resident with multiple chronic conditions was discharged home with a three-day supply of medications, but the facility did not send prescriptions to the external pharmacy until eight days later, causing a delay in medication access. Additionally, the facility failed to notify Social Security of the discharge within a timely manner, with notification occurring 13 days after discharge due to internal communication and equipment issues.
A resident with a PEG tube was affected by a medication administration error when an LPN failed to follow updated physician orders and facility policy. The resident, who had begun eating and taking fluids orally, was supposed to receive medications crushed in applesauce or pudding. Instead, the LPN attempted to administer the medications through the PEG tube without adding water, causing it to clog. The DON confirmed the error and the need for reviewing orders before administration.
An LPN at the facility failed to adhere to proper medication administration protocols, affecting three residents. A resident with a PEG tube received medications incorrectly, leading to a clogged tube. Another resident was exposed to potential medication errors due to the LPN preparing medications for multiple residents simultaneously. Additionally, a resident with diabetes received insulin injections improperly, with discrepancies in blood glucose documentation.
A facility failed to maintain a medication error rate below 5%, with an LPN making 11 errors affecting three residents. Errors included improper administration through a PEG tube, failure to start a nebulizer treatment, and incorrect insulin administration. The LPN did not adhere to physician orders or facility policies, leading to a 19% error rate.
A resident with diabetes type two received insulin injections that were not administered according to the manufacturer's guidelines. An LPN failed to hold the insulin pen in place for the required 10 seconds, administering the injection too quickly. Additionally, there was a discrepancy in the documented blood glucose level, with the LPN recording a different value than what was observed. The DON confirmed these actions were not in compliance with facility policies.
The facility failed to provide physician-ordered medications to two residents, resulting in a deficiency. One resident with severe cognitive impairment and GERD did not receive Famotidine on multiple occasions due to unavailability. Another resident with moderate cognitive impairment and GERD missed doses of Omeprazole, with records indicating the medication was out of stock or unavailable. The DON confirmed these issues, noting a lack of documentation for marking the medication as not required.
A facility failed to ensure residents were free from significant medication errors, affecting three residents. A resident with severe cognitive impairment missed multiple doses of Novolog insulin, while another missed a dose of Lantus insulin. A third resident with intact cognition did not receive a morning dose of Insulin Glargine. These incidents were confirmed by the DON and indicate non-compliance with the facility's medication administration policy.
A facility failed to ensure proper infection control when an RN did not wear gloves while administering insulin to a resident with type II diabetes. The facility's policy requires gloves for tasks involving potential exposure to blood or body fluids. The RN confirmed the oversight during an interview.
The facility failed to administer medications per physician orders and maintain controlled substance records, affecting four residents. Errors included administering the wrong antibiotic to a resident and failing to document the administration of oxycodone and morphine for others. These issues highlight lapses in medication management and documentation procedures.
A facility failed to complete a comprehensive care plan for a resident with impaired cognition and incontinence. Despite the resident's diagnoses and continuous incontinence, the care plan lacked an incontinence care section. Interviews confirmed the oversight, and the facility's policy mandates completion within seven days post-assessment.
The facility failed to provide a resident with the prescribed two-handled cup for drinking, despite the resident's severe cognitive impairment and need for assistance. Observations showed drinks were in smooth cups without handles and placed out of reach. Interviews confirmed the deficiency, revealing a lack of communication between nursing staff and the kitchen.
Failure to Complete Physician-Ordered Wound Treatments
Penalty
Summary
A deficiency occurred when wound treatments for a resident with multiple chronic wounds, including non-pressure ulcers on the right foot and calf, were not completed as ordered by the physician. The resident's medical record showed daily wound care orders, including cleansing with normal saline, application of calcium alginate with silver, and appropriate dressings. Documentation on the Treatment Administration Record (TAR) indicated that treatments were recorded as completed on consecutive days, but interviews and direct observation revealed that the treatments had not actually been performed. Specifically, the wound dressings had not been changed since two days prior, as evidenced by the date and staff initials on the gauze, and the resident reported not receiving wound care since the beginning of the week. Further investigation through staff interviews confirmed that one LPN documented completion of wound care before actually performing it, and another LPN admitted to not completing the treatment due to running out of time during the shift. There was no documentation in the resident's chart explaining the missed treatments, and the Director of Nursing confirmed that the wound care should have been completed as ordered. The deficiency was identified during a complaint survey and was substantiated by resident interview, staff interview, record review, and direct observation.
Failure to Provide Residents with Selected Menu Items
Penalty
Summary
The facility failed to ensure that residents received the menu items they selected at mealtime, as evidenced by observations, interviews, and review of records. Two residents with intact cognition and specific medical diagnoses, including hemiplegia, type II diabetes mellitus, hypertensive heart disease, and heart failure, did not receive the food items they had chosen on their meal tickets. One resident did not receive vegetable soup as selected, and another did not receive crackers, despite both items being available and provided only after staff intervention during the meal service. Staff interviews confirmed that residents frequently complained about not receiving their requested menu items. Further review revealed that CNAs were responsible for distributing and collecting menu tickets, but there were ongoing issues with ensuring residents' selections were honored. Resident Council Food Committee notes documented concerns about menus not being filled out and residents not getting what they requested. These findings demonstrate a pattern of the facility not providing food according to residents' documented preferences and selections.
Failure to Complete Post-Fall and Neurological Assessments and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that post-fall assessments, including neurological assessments, were completed for residents who experienced unwitnessed falls. Specifically, two residents with histories of falls did not receive neurological assessments after their unwitnessed falls, despite facility protocol requiring such assessments. Additionally, post-fall assessments were not completed for certain incidents. Interviews with the Regional Director of Clinical Services and the Director of Nursing confirmed that these assessments were not performed as required. Review of facility policies revealed a lack of clear guidance regarding neurological assessments after unwitnessed falls, and documentation did not support that follow-up was conducted as outlined in the fall reduction policy. The facility also failed to implement and document fall prevention interventions for a resident at risk for falls. This resident, with diagnoses including Alzheimer's disease and dementia, experienced multiple falls where prescribed interventions such as non-skid socks and use of a walker were not in place at the time of the incidents. Documentation did not confirm whether the resident was compliant with these interventions, and new interventions were added after each fall without evidence of consistent implementation. These failures were identified through observation, staff interviews, record review, and policy review.
Failure to Provide Timely Discharge Medications and Notification to Social Security
Penalty
Summary
The facility failed to ensure a resident received timely access to prescribed medications upon discharge and did not provide timely notification to Social Security (SS) regarding the resident's discharge. The resident, who had multiple diagnoses including frontotemporal neurocognitive disorder, diabetes, hypertension, and multiple myeloma, was discharged to his home with a three-day supply of medication. However, the prescriptions for ongoing medications were not sent to the external pharmacy until eight days after discharge, resulting in a delay in the resident receiving his medications. Staff interviews confirmed that the discharge prescriptions were not sent as intended, and there was no confirmation of the prescriptions being faxed on the day of discharge. Additionally, the facility did not notify SS of the resident's discharge in a timely manner. The Business Office Manager (BOM) acknowledged that notification to SS was delayed by 13 days due to issues with the fax machine and lack of access to alternative faxing methods. The BOM also stated that there was no written policy regarding the timeframe for SS notification at the time of the incident, and that previous guidance allowed for up to 30 days, which was later changed to three days by the corporate office. The deficiency was identified through review of the electronic medical record, external pharmacy records, staff and family interviews, and facility policy. The resident involved was cognitively intact at the time of discharge, and interviews with the resident and his son indicated that no physical or psychosocial harm resulted from the delay in medication. The facility's discharge summary policy required reconciliation of all pre- and post-discharge medications, but this process was not completed in a timely manner for this resident.
Medication Administration Error via PEG Tube
Penalty
Summary
The facility failed to ensure medications were administered via feeding tube per physician orders for Resident #15, who was admitted with diagnoses including sick sinus syndrome, traumatic brain injury, dysphagia, and dementia. The resident's care plans indicated the use of a PEG tube for nutrition and medication administration due to dysphagia. However, on 03/25/25, the physician orders were updated to allow medications to be crushed in applesauce or pudding and taken orally, as the resident had begun eating and taking fluids by mouth. Despite this change, an LPN prepared and attempted to administer the resident's medications through the PEG tube without adding water to the crushed pills, causing the tube to clog. The LPN was unaware of the updated orders and did not follow the facility's policy for medication administration via feeding tube, which requires medications to be crushed finely and mixed with water to prevent clogging. The Director of Nursing confirmed the oversight and noted the need for reviewing physician orders prior to medication administration.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure that nursing care was provided in accordance with standards and practices, affecting three residents during medication administration. Resident #15, who had a PEG tube for feeding due to dysphagia, was observed receiving medications incorrectly. The LPN prepared and attempted to administer crushed medications through the PEG tube without adding water, causing the tube to clog. The LPN did not review the updated physician orders, which had changed the route of medication administration to oral, and was unaware of the resident's fluid restrictions. Resident #16, who had intact cognition and was on multiple medications, was affected by the LPN's practice of preparing medications for multiple residents simultaneously. The LPN was observed entering Resident #16's room with medications for another resident, which is against facility policy. This practice increases the risk of medication errors and demonstrates a lack of adherence to proper medication administration protocols. Resident #18, who had diabetes and was receiving insulin injections, was also impacted by the LPN's improper practices. The LPN administered insulin using a Flex-pen without holding the needle in the skin for the recommended 10 seconds, as per the manufacturer's guidelines. Additionally, there was a discrepancy in the recorded blood glucose level, which was documented incorrectly in the resident's MAR. These actions indicate a failure to follow established procedures for insulin administration and accurate documentation.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 19% affecting three residents. During a medication administration observation, an LPN was noted to have made 11 medication errors while administering medications to three residents. The errors included improper administration techniques and failure to adhere to physician orders. For Resident #15, the LPN attempted to administer medications through a PEG tube despite the resident's orders having been changed to oral administration. The LPN did not add water to crushed medications before attempting to administer them through the PEG tube, resulting in the tube becoming clogged. The LPN was unaware of the resident's fluid restrictions and did not review the updated physician orders prior to administration. Resident #17 did not receive a nebulizer treatment as ordered because the LPN failed to turn on the nebulizer machine and did not verify the start of the treatment. For Resident #18, the LPN prepared medications for multiple residents simultaneously, entered a room with another resident's medications, and administered insulin too quickly, not adhering to the facility's policy of holding the insulin pen for 10 seconds. Additionally, the LPN documented an incorrect blood glucose reading in the resident's MAR.
Improper Insulin Administration and Documentation Discrepancy
Penalty
Summary
The facility staff failed to properly administer insulin medications according to the manufacturer's guidelines, affecting one resident. The resident, who has diabetes type two, was observed receiving insulin injections that were not administered correctly. The LPN responsible for administering the insulin did not follow the facility's policy of holding the insulin pen in place for a full 10 seconds after injection, as required by the manufacturer's guidelines. Instead, the LPN administered the injection quickly and removed the pen immediately, which was not in line with the facility's practice. Additionally, there was a discrepancy in the documentation of the resident's blood glucose levels. The LPN documented a blood glucose level of 216 in the Medication Administration Record (MAR), whereas the actual observed level was 228. This inconsistency in documentation further highlights the deficiency in the administration of medication. The Director of Nursing confirmed that the LPN's actions were not in compliance with the facility's policies, and the LPN was responsible for administering medications to all residents in the facility.
Medication Availability Deficiency for Two Residents
Penalty
Summary
The facility failed to ensure that physician-ordered medications were available and administered to two residents, leading to a deficiency. Resident #26, who was severely cognitively impaired and had multiple diagnoses including GERD, did not receive the prescribed Famotidine on several occasions due to the medication being unavailable. The medication administration record (MAR) and nurse progress notes indicated that the medication was on order or not available on the specified dates, which was confirmed by the Director of Nursing (DON). Similarly, Resident #80, with moderate cognitive impairment and a diagnosis of GERD, did not receive the prescribed Omeprazole on multiple dates. The MAR and nurse progress notes documented that the medication was unavailable or out of stock, and there was no documentation to support the medication being marked as not required on one occasion. The DON confirmed the non-administration of the medication and noted the absence of any hold parameters in the physician's order that would justify the medication being marked as not required.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting three out of five residents reviewed. Resident #26, who was severely cognitively impaired, did not receive the ordered sliding scale dose of Novolog insulin on three separate occasions. This was confirmed by the Director of Nursing (DON) during an interview. Resident #26 had multiple diagnoses, including diabetes mellitus, hemiplegia, and vascular dementia, which required careful management of their medication regimen. Resident #89, also severely cognitively impaired, did not receive the scheduled afternoon dose of Lantus insulin on one occasion. Similarly, Resident #93, who had intact cognition, missed a morning dose of Insulin Glargine. The facility's policy on medication administration, which mandates that medications be administered as prescribed, was not adhered to in these instances. These deficiencies were identified during a complaint investigation, highlighting non-compliance with the facility's medication administration guidelines.
Failure to Wear Gloves During Insulin Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during medication administration. Specifically, a Registered Nurse (RN) did not wear gloves while administering 16 units of Lantus SoloStar Solution Pen-injector to a resident with type II diabetes mellitus. This incident was observed during a medication administration session. The facility's policy, revised on 08/09/16, mandates that all personnel must wear gloves when performing tasks that involve potential exposure to blood or body fluids, including when working with sharp items. The RN confirmed during an interview that gloves were not worn during the administration of the insulin injection.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders and did not maintain proper controlled substance drug records, affecting four residents. For Resident #118, a medication error occurred when a registered nurse administered cefazolin instead of the prescribed ceftriaxone. The error was documented, and the resident experienced no adverse effects. However, there was no documentation for the indication of use for the medication. For Resident #24, there was a discrepancy in the controlled substance records, with 17 doses of oxycodone-acetaminophen being pulled from the medication card but not documented as administered in the medication administration record. Similarly, for Resident #84, seven doses of oxycodone were removed from the medication card without documentation of administration. These discrepancies indicate a failure to properly document the administration of controlled substances. Resident #117's records revealed that 16 doses of morphine sulfate were administered without a corresponding controlled substance record. The facility was unable to locate the documentation for these doses. The facility's policies require that controlled medications be documented immediately upon removal and administration, but these procedures were not followed, leading to the deficiencies noted in the report.
Incomplete Comprehensive Care Plan for Incontinence
Penalty
Summary
The facility failed to ensure a comprehensive care plan was timely completed for a resident with multiple diagnoses, including chronic obstructive pulmonary disease, chronic kidney disease, vascular dementia, and atrial fibrillation. The resident, who was admitted on an unspecified date, was found to have impaired cognition and was always incontinent of bowel and bladder according to the admission Minimum Data Set (MDS) assessment. Despite these findings, the comprehensive care plan dated October 1, 2024, and last revised on October 12, 2024, did not include a care plan for incontinence care. Interviews with facility staff revealed that the resident was unaware of their incontinence, and the MDS Coordinator confirmed that the comprehensive care plan was incomplete. The facility's policy, last revised in November 2016, requires that a comprehensive care plan be developed within seven days after the completion of the comprehensive assessment. However, this requirement was not met, as verified by the MDS Coordinator, who acknowledged the omission of the incontinence care plan for the resident.
Failure to Provide Assistive Drinking Devices
Penalty
Summary
The facility failed to ensure that Resident #27 was provided with assistive devices as ordered and care planned. Resident #27, who had severe cognitive impairment and required assistance for activities of daily living, was supposed to use a two-handled cup with a lid for all drinks. Despite this, multiple observations revealed that the resident's drinks were provided in smooth cups with lids and no handles, and the cups were often placed out of the resident's reach. This was confirmed through observations on several dates, where the resident's drinks were consistently not in the prescribed two-handled cups and were placed on an over-the-bed table that was not accessible to the resident due to fall prevention measures in place in the room. Interviews with the Director of Nursing (DON) and the Food Service Supervisor (FSS) confirmed the deficiency. The DON acknowledged that the resident's drinks were not in the appropriate cups and were not within reach, explaining that staff would offer the resident a drink when they entered the room. The FSS revealed that the kitchen had not been informed to provide the two-handled cup for the resident's meals, as nursing staff had not filled out the necessary dietary slip. This deficiency was investigated under Master Complaint Number OH00152085.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Perrysburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Three Meadows Post Acute | 0.8 mi | — | 13 | 1 |
| Avalon By Otterbein At Perrysburg | 0.8 mi | — | 0 | 0 |
| Kingston Health Center Of Perrysburg | 1 mi | — | 0 | 0 |
| Concord Care Center Of Toledo | 3.4 mi | — | 5 | 0 |
| Majestic Care Of Perrysburg | 3.6 mi | — | 16 | 0 |
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